Diagnostic Imaging Services Targeted Probe and Educate Review Results - JF Part A
Diagnostic Imaging Services Targeted Probe and Educate Review Results
The Jurisdiction F, Part A Medical Review Department is conducting a Targeted Probe and Educate (TPE) review on a variety of diagnostic imaging service codes. The findings of the claims reviewed from July 1, 2025 through September 30, 2025 are as follows:
Review Results
- 515 claims were reviewed with 3.0% error rate
Top Trending Errors
- Medical necessity of specific diagnostic imaging on review
- Documentation requirements for diagnostic imaging services
- Preventative and screening services
Educational Resources
- Documentation Requirements
- National Coverage Determination (NCD)
- Local Coverage Determination (LCD)
- Preventative Services.
- Radiology
- IOM, Publication 100-02, Medicare Benefit Policy Manual (MBPM), Chapter 15, Section 80
- IOM, Publication 100-04, Medicare Claims Processing Manual (MCPM), Chapter 13
- Medicare Coverage Database (MCD) Search
Education
Documentation to Support Medical Necessity
The practitioner that orders a service must maintain documentation to support medical necessity for that service in the beneficiary’s medical record. It is the responsibility of the provider submitting the claim to maintain documentation that is received and that it reflects the information received from the ordering practitioner. The submitting provider may request additional information from the ordering practitioner to support the service billed is reasonable and necessary as laid out in the Social Security Act 1862.
Upon receipt of the Additional Development Request (ADR), the billing provider must submit documentation of an order for the service, which includes information to identify and contact the ordering practitioner, to verify appropriate completion of the order and services billed.
For additional information on record keeping supporting medical necessity of billed claims, refer to 42 Code of Federal Registry (CFR) section 410.32.
Documentation Supporting Services Rendered
Under section 1833(e), Title XVIII of the Social Security Act (SSA) states, "no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period."
No Medicare payment can be made for claims that lack the necessary information for processing. Medicare claims will be allowed to process, when there is sufficient documentation in the patient’s records to verify the services were performed and were medically necessary and reasonable for the medical condition. Justification for the service may be documented in the physician’s clinic or hospital progress notes and/or laboratory results. If there is no documentation, or insufficient documentation to support the service, then Medicare considers the service not rendered and services will be denied.
Screening Services
When services are performed for preventive care, physician preference, or screening purposes, the underlying purpose for completion of these services does not support medical necessity for diagnosis or treatment. Screening services performed in the absence of signs, symptoms, complaints, personal history of disease, or injury are not covered except when there is a statutory provision for these services as described in the Medicare coverage manuals. The outcome or result of the service does not support medical necessity, as the performance of the service is originally intended as screening.
For additional information, reference the Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual (MCPM), Chapter 18.
