Radiology Documentation Requirements

It is expected that patient's medical records reflect the need for care/services provided. The listing of records is not all inclusive. Providers must ensure all necessary records are submitted to support services rendered. They may include:

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Brief Description
Beneficiary identification, date of service, and provider of the service should be clearly identified on each page of the submitted documentation
Practitioner, nurse, and ancillary progress notes
Diagnostic tests, radiological reports, lab results, pathology reports, and other pertinent test results and interpretations
Documentation to support type and amount of contrast given
Interpretive statement, which specifically explains the test results and how it will be used in the beneficiary's care
Documentation from the prescribing/ordering provider to support the medical necessity of the service
Physician/Non Physician (NPP) order or evidence of intent to order
Physician referral (prescription, treatment or diagnostic test)
Documentation supporting the diagnosis code(s) required for the item(s) billed
Documentation to support the code(s) and modifier(s) billed
List of all non-standard abbreviations or acronyms used, including definitions
-Any other supporting/pertinent documentation
Documentation to support National Coverage Determination (NCD), Local Coverage Determination (LCD) and/or Policy Article
Signatures are required for medical review for the following purposes: 1) To satisfy specific signature requirements in statute, regulation, national coverage determination (NCD) or local coverage determination (LCD); and 2) To resolve authenticity concerns related to legitimacy of falsity of the documentation
If an electronic health record is utilized, include your facility's process of how the electronic signature is created. Include an example of how the electronic signature displays once signed by the physician
Advance Beneficiary Notice of Non-Coverage (ABN)/Notice of Medicare Non-Coverage (NOMNC)

Multiple CMS contractors are charged with completing reviews of medical records. See Identifying Which Entity Completed a Part B Claim Review for detailed information about each of these contractors.

Documentation Submission

Once a provider compiles all the necessary documentation, it is important to submit them to the appropriate contractor according to the request received. Select the request below to view the appropriate submission instructions.

View the Radiology webpage for additional information and resources.

Last Updated Mar 21 , 2025

Documentation Requirements Disclaimer

The documentation requirements contents/references provided within this section were prepared as educational tools and are not intended to grant rights or impose obligations. Use of these documents are not intended to take the place of either written law or regulations.

The listing of records is not all inclusive. Providers must ensure all necessary records are submitted to support services rendered.

Important that physician intent, physician decision and physician recommendation to provide services derived clearly from the medical record and properly authenticated.

The submission of these records shall not guarantee payment as all applicable coverage requirements must be met.