Medical Necessity & CPT Codes
Appropriateness codes support insurance coverage.
Following the guidelines below can enhance care quality, promote the effective use of radiology and reduce overall healthcare costs. Insurance providers require that radiology exams include medical necessity information as well as appropriate CPT codes. Without a covered diagnosis, your patient – not the insurer – will pay for imaging services. Adding medical necessity information benefits your patient.
THE RIGHT EXAM
Use CMS-approved appropriateness criteria to ensure the right exam is ordered and provide specific CPT codes when available. Learn more below.
Certain radiology exams must meet medical necessity criteria before they can be authorized and/or covered by insurance. Learn more below.
SUBMIT IMAGING ORDERS
Submit orders that detail the patient’s condition including specific location, severity, context, and symptoms for their designated condition.
A handwritten or electronic provider / physician signature is required on all orders.
Avoid Making These Common Mistakes When Ordering Radiology Exams
- Diagnosis or working symptoms – It’s important that our radiologists understand a patient’s clinical conditions to ensure that appropriate imaging is being performed. Do not order “rule out” exams unless a patient’s history and symptoms are fully detailed.
- Valid Signature – Legible handwritten or valid electronic signatures are the only types of signatures we accept. Stamped signatures are not considered valid.
- Exam description or CPT code – Provider notes aid in ensuring the correct exam is being performed. Resources for clinical decision support include our radiologists and the ACR Appropriateness criteria guide.
- Comparison Studies – Let us know if there are prior studies that can be used for comparison.
Resources for Meeting Medical Necessity
Questions about medical necessity? Call our coding team at 919-787-8221 ext. 1290