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Pre-Procedure Imaging Requirements for Medical Review of Claims

Noridian Medical Review team has identified errors related to lack of documentation supporting imaging completed prior to a surgical intervention. Imaging is required to support the medical necessity of that surgical procedure. This clarifies the components of the pre-procedure imaging that must be submitted in order to support the medical necessity of any procedures being performed.

Many providers experience difficulty with obtaining medical records if the pre-procedure imaging was completed at an outside facility. To help providers, Noridian has established guidelines when no official pre-procedure imaging report is available, the following components must be present within the medical records:

  • Date imaging was completed
  • Type of imaging/exam
    • Examples include: x-ray, magnetic resonance imaging (MRI), or echocardiogram
  • Findings
    • A detailed summary of what imaging revealed, if no formal imaging report is available

The below will assist providers in identifying if the components that are required for pre-procedure imaging are present in the documentation being submitted.

Acceptable Pre-procedure Imaging Documentation Example

  • MRI (1/1/14): Left knee shows periarticular osteophytes and joint subluxation.

Unacceptable Pre-procedure Imaging Documentation Example

  • Imaging shows advanced osteoarthritis.

Without the appropriate pre-procedure imaging components being present in the documentation, Noridian is unable to provide an accurate review of the medical necessity of the procedure being performed, which may result in the claim being denied.

Last Updated Sep 29, 2015