Educating Radiologists on Denials Caused by NCDs, LCDs, & Articles

Radiology groups are facing increased pressure to ensure the financial sustainability of their practices. While most radiologists are deeply skilled in medical imaging and patient care, navigating the complexities of medical billing can be a significant challenge. This barrier can sometimes lead to insufficient detail in physician reports, which can cause denials based on National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and Policy Articles. These denials have potentially significant financial repercussions. This article aims to empower radiologists with a foundational understanding of these policies and equip them with practical strategies to minimize denials and optimize revenue cycle management.

What are NCDs, LCDs, and Policy Articles?

NCDs are broad, nationwide policies issued by the Centers for Medicare & Medicaid Services (CMS) that determine whether Medicare will cover specific medical items or services. LCDs are more specific policies developed by Medicare Administrative Contractors (MACs) within particular geographic regions. LCDs provide detailed criteria for coverage of services within their respective areas, including a list of medically necessary International Classification of Diseases, Tenth Revision (ICD-10) codes for a specific Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPC). Policy Articles are supplementary documents issued by CMS that provide additional information, clarifications, and updates related to NCDs and LCDs. They may address specific questions, announce policy changes, or offer guidance on interpreting existing coverage criteria. 

NCDs, LCDs, and Articles establish strict criteria for Medicare coverage of radiology services. Compliance with these policies is necessary for ensuring reimbursement and avoiding costly denials. Non-compliance, often stemming from inadequate documentation of medical necessity in radiology reports, can significantly impact the financial health of radiology practices, particularly in the face of ongoing challenges such as Medicare Physician Fee Schedule (MPFS) cuts. If radiologists have a practical understanding of these policies, it will better equip them and their practices with strategies to minimize denials and optimize revenue cycle management.

Role of Documentation

Radiology reports serve as the cornerstone for demonstrating medical necessity and securing appropriate reimbursement. Clear and concise documentation is important, as it provides a comprehensive record of the examination, clinical indications, findings, and interpretations. 

Essential elements for supporting reimbursement include: 

1. Precise and accurate examination descriptions, including the technique used, the number of images acquired, and any contrast agents administered.
2. Detailed clinical history and indications, meaning the report should clearly state the reason for the exam, including the patient's relevant medical history, presenting symptoms, and the referring physician's clinical questions. 
3. Comprehensive findings, including a detailed and objective description of all relevant findings, including normal and abnormal observations. 
4. A clear and concise interpretation should be well-supported by the radiologist's findings, correlate to the clinical indications, and document incidental findings and recommended follow-up needed when the radiologist feels it is beneficial. 
5. Accurate and consistent use of medical terminology ensures clear communication and facilitates proper coding and billing. 

By documenting these key elements, radiologists can effectively demonstrate medical necessity, enhance communication with referring physicians, and improve the overall efficiency and accuracy of the revenue cycle. 

Identifying Charges That Will Deny At Time of Coding

Coders follow CPT and ICD-10 guidelines to assign compliant codes based on the dictated radiology report. These codes are submitted to the insurance company for reimbursement of services. When reviewing the radiology report, the coder may find that the radiology report does not support a CPT and ICD-10 combination that will be reimbursed based on the published NCD, LCD, or Article. If a covered ICD-10 code is not located on the radiology report, the coder may extract signs/symptoms from the referring doctor's order. The coder is not allowed to extract ICD-10 information from the technician notes (ICD-10 manual, B. General Coding Guidelines; Rule 14). If the report lacks ICD-10 criteria to support medical necessity, typically a  policy is developed to follow one of the following protocols: 

• The report is coded as is, knowing that the payer will deny the claim, resulting in non-payment. This approach is not recommended. 
• The report is flagged for addendum review and sent back to the radiologist so they can review it. This review process allows for the necessary information to be added to the report if available, and it is then sent back to the coder to re-review the report and code with an ICD-10 code that the payer deems as medically necessary. This approach is recommended. 

Opportunity For Solutions To Be Implemented

Establishing a coding team or software that identifies charges that will be denied against LCD, Article, or NCD policies presents an opportunity for the radiology practice to determine the cause of the unavailable medically necessary ICD-10 code. Once the cause is determined, a strategy to reduce denials can be determined. Below are some examples of the causes and possible solutions to rectify the issue. 

Cause #1:
The radiologist has additional diagnosis information that the coding team is unable to view. The radiologist could add this information to the impression as a covered disease or an indication as a covered sign or symptom.

• Solution: Educate radiologists on LCDs, Articles, and NCDs affecting the radiology tests they provide. This knowledge will allow them to addend current requests and provide needed information in the future to minimize addendum requests. 
• Solution: Revise templates to prompt radiologists to thoroughly review all provided documentation, including the referring physician's order and the technologist's notes, ensuring the diagnosis captured meets the medical necessity requirements of the payers.

Cause #2:
The technologist has additional information that they can provide to the radiologist, allowing them to add to the impression of a covered disease or indication as a covered sign or symptom.

• Solution: Educate your technologists on LCDs, Articles, and NCDs to obtain accurate information supporting medical necessity. 
• Solution: The radiologist can review the technologist’s notes for additional patient-provided information to add to the radiology report, as allowed. 

Cause #3:
The referring doctor has additional information that can be provided on the order, which could indicate a covered sign or symptom. 

• Solution:  “Federal law [42 USC 1395u(p)] requires the ordering physician to provide diagnostic information at the time the exam is ordered. The law states that when the entity furnishing a service (in this case, the imaging facility) is required to submit diagnostic information to receive payment for the service, the ordering physician or practitioner ‘shall provide that information to the entity at the time the item or service is ordered by the physician or practitioner.’ CMS expects that providers will use the information from the referring physician to determine whether the exam meets the NCD or LCD requirements for coverage.” (Source: Revenue Cycle Coding Strategies Navigator 2023 Diagnostic Radiology Billing Compliance)
• Solution: Schedulers can be trained on LCD, Article, and NCD requirements and query the referring physician at the time the exam is scheduled to obtain the additional information needed to support medical necessity as per the payer guidelines. 
• Solution: If an exam is scheduled without the appropriate information, a follow-up call can be made to the referring physician to obtain additional signs and symptoms information that support medical necessity.

Cause #4:
The referring doctor is ordering exams that the payers identify as not medically necessary, and they do not have additional information to supply. 

• Solution: Referring physicians who order exams that payers deem not medically necessary can receive education on LCDs, Articles, and NCDs.
• Solution:  If it is determined that a payer will not cover an exam, an Advance Beneficiary Notice (ABN) can be issued when appropriate. An ABN is a document that informs Medicare beneficiaries that a particular service may not be covered by Medicare. It allows the beneficiary to make an informed decision about whether to proceed with the service and accept potential financial responsibility. Please note that for current ABNs to be used, all necessary fields of the ABN must be filled out, and payer requirements must be reviewed to know which payers will allow for ABNs to be utilized. When Medicare denies coverage and the beneficiary has signed an ABN, they are generally responsible for paying for the service out-of-pocket.

Other Exams That Cause Denials that Follow Medicare Guidelines 

There are also exams that are denied by Medicare and payers that follow Medicare guidelines, but are not related to LCDs, Articles, or NCDs. The same causes and solutions may be able to be applied in the following cases: 

• Preoperative Chest  X-Ray
  • Many payers require the reason for the surgery to be coded in addition to the preoperative code to get paid for the chest x-ray. ICD-10 Guidelines Section IV.M provides the following instruction: “For patients receiving preoperative evaluations only, sequence first a code from subcategory Z01.81, Encounter for pre-procedural examinations, to describe the pre-op consultations. Assign a code for the condition to describe the reason for the surgery as an additional diagnosis. Code also any findings related to the pre-op evaluation.” (Source: ICD-10-CM Official Guidelines for Coding and Reporting FY 2024)
• Medicare Preventive Services 
  • Medicare Preventive Services are a set of health services that are covered by Medicare without requiring a deductible or copayment, including exams such as: 
    • Lung Cancer Screening with Low Dose Computed Tomography (LDCT)
    •  Bone Mass Measurements
    • Ultrasound AAA Screening, Mammography Screening.
  • While some exams classified as Medicare Preventive Services are covered under LCDs and NCDs, not all fall within these guidelines. Medicare Preventive Services without an assigned LCD or NCD must still meet specific criteria to be considered medically necessary, including, but not limited to, proper ICD-10 code assignment.
• Any tests ordered for “rule out” 
  • Coders are unable to compliantly code any indication deemed as a “rule out” according to ICD-10 guidelines section IV.H (Uncertain Diagnosis): “Do not code diagnoses documented as ‘probable’, ‘suspected,’ ‘questionable,’ ‘rule out,’  ‘compatible with,’ ‘consistent with,’ or ‘working diagnosis’ or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.” (Source: ICD-10-CM Official Guidelines for Coding and Reporting FY 2024) This guideline means coders should not assign a code for a diagnosis that is documented as being "ruled out" in outpatient settings. Instead, they should focus on coding the symptoms or reasons for the visit until the diagnosis is confirmed.

Practical Applications

Radiology practices should actively engage their revenue cycle management companies to help create strategies to minimize these denials. It is necessary to carefully review referring physician orders to ensure they contain all necessary clinical information, including specific diagnoses or symptoms, to support medical necessity. Radiologists can utilize existing templates and checklists within the radiology information system (RIS) to guide report documentation and ensure adherence to payer guidelines. Radiologists can also foster open communication with coders or their billing companies to participate in reviews and actively address these coding challenges. Finally, radiologists need time and be open to understanding the changes to NCDs, LCDs, and other relevant policies through regular professional development activities and education. By implementing these proactive measures, radiologists can significantly improve claim accuracy, reduce denials, and ultimately enhance the financial stability of their practices.

Conclusion

In conclusion, understanding and adhering to NCDs, LCDs, and Articles is one of the important aspects of medical billing to learn to ensure accurate coding, optimize reimbursement, and maintain the financial health of radiology practices. By fostering open communication with coders, actively reviewing referring physician orders, and implementing strategies to improve documentation within radiology reports, radiologists can minimize denials stemming from non-compliance with these CMS policies. Radiology practices need to pursue continuous professional development and a proactive approach to identify and address potential coding challenges to navigate the evolving medical billing landscape and ensure radiology practices' long-term success.

Turn Policy Knowledge into Practice Profit. Understanding CMS policies is the first step; implementing them is the second. Dexios offers specialized radiology consulting to help your practice minimize denials and maximize reimbursement.

[Connect with a Dexios Consultant Today]