November 05, 2020

CMS Issues Special Provisions for Radiology Documentation Requests

On Oct. 30, The Centers for Medicare and Medicaid Services (CMS) issued MLN Matters Number: MM11659 Special Provisions for Radiology Additional Documentation Requests. This change request discusses a pilot process enabling Medicare Administrative Contractors (MACs) to request pertinent documentation from the treating/ordering provider during medical review, in an effort to support the necessity and payment for radiology service(s) or item(s) billed to Medicare. The effective implementation date is scheduled for Dec. 1, 2020. There are instances in which radiology service providers selected for review are unable to acquire supporting documentation, possibly retained by the treating/ordering practitioner. This pilot process supports CMS’s program of integrity activities.

The American College of Radiology® (ACR®) Contractor Advisory Committee (CAC) Network appreciates CMS issuing this guidance to MACs and treating/ordering providers. “This is a big deal and something we have been pushing for years,” says a longtime ACR CAC representative.

The MAC has the ability to auto-deny a claim if a benefit category, statutory exclusion or coding issue is in question, or to send an Additional Documentation Request (ADR) to the provider selected for review, in order to review records to determine whether the claim is payable and medically necessary. Prior to this change, upon request for medical records by the MAC, Comprehensive Error Rate Testing contractor, Recovery Auditor and/or Unified Program Integrity Contractor, it was the responsibility of the provider selected for review to obtain supporting documentation as needed from the treating/ordering provider’s office (for example, a physician order or notes that support medical necessity). If sufficient documentation was not provided, the payment to the provider selected for review, such as a radiologist, would be at risk.

MACs are now required to conduct third-party ADRs for radiology service claims, when necessary, from the treating/ordering practitioner, e.g., a physician’s office or inpatient facility, and identify data to be reported by the MACs for assessment of the pilot. A reporting template is suggested.

The official instruction, CR11659, issued to local MACs regarding this change is available online. If you have questions, contact your local MACs for more information.