Chest X-Ray Quarterly Results of TPE Review - JE Part A
Chest X-Ray Targeted Probe and Educate Review Results
The Jurisdiction E, Part A Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of CPT® 71045 - Radiologic examination, chest; single. The quarterly edit effectiveness results from January 1, 2020 through March 31, 2020 are as follows:
Top Denial Reasons
- Documentation does not support coverage and medical necessity requirements per LCD.
- Radiology Documentation Requirements
- Local Coverage Determination (LCD) for Chest X-Ray (L37547)
- Local Coverage Article: Billing and Coding: Chest X-Ray Policy (A57497)
- IOM, Internet Only Manual, Medicare Benefit Policy Manual (MBPM), Publication 100-02. Chapter 15, Section 80
- IOM, Publication 100-04, Medicare Claims Processing Manual (MCPM), Chapter 13, Section 100
- IOM, Publication 100-08, Medicare Program Integrity Manual (MPIM), Chapter 3
Limitations of Coverage for Chest X-rays
Local Coverage Determination (LCD) L37547 provides coverage requirements for chest X-rays. Radiologic examination of the chest (chest X-ray) facilitates the detection, diagnosis, staging and management of pathophysiologic processes involving thoracic, cardiovascular, pulmonary and mediastinal structures, contiguous coverings and the bony thorax. Medicare Part A covers these examinations when medically necessary and appropriate for evaluation and management of a specific symptom, sign, disease or injury.
Routine, screening, pre-operative or periodic examinations in the absence of signs, symptoms, or disease states rarely adds significant clinical information per the cited references in the LCD and therefore will not be reimbursed. Chest X-rays completed solely for the purpose of evaluating minor trauma of the head, lower back or extremities would not be considered medically necessary. Documentation must support the signs and symptoms warranting a chest x-ray or supporting information on how the chest X-ray results will influence treatment of the beneficiary.
Note: Local Coverage Article: Billing and Coding: Chest X-Ray Policy A57497 lists diagnosis codes that do not support medical necessity per standard medical practice. The codes listed are non-covered diagnosis codes.
Last Updated Thu, 21 May 2020 21:01:28 +0000