Radiology Audits: A New Pilot Program from CMS

Radiology Image

This is the all too familiar scenario.  An order for radiology services is received, the patient is scheduled, and services are rendered.  And now there’s an audit.  The radiology provider is on the hook to prove that services were medically necessary.  And the chase for documentation from the ordering provider begins.

Meanwhile, the ordering provider has received payment but ignores the radiology provider’s request for records that demonstrate medical necessity. Time passes and the audit concludes without any documentation from the ordering provider.  If the radiology provider cannot supply documentation requested to support the medical necessity of the service the radiology provider is subject to an overpayment.  Often, the medical necessity for radiology services resides in the ordering provider’s documentation or hospital record.

A new pilot program that specifically targets radiology services may help eliminate the inevitable frustration that ensues when documentation is not forthcoming from ordering providers.  The Centers for Medicare and Medicaid Services (CMS) announced the program for audits with radiology effective with date of service December 1, 2020.[1]

This pilot program shifts the burden of providing documentation that demonstrates medical necessity from radiology providers to ordering providers.  Medicare Administrative Contractors (MAC) will be able to request documentation from treating and/or ordering providers.  This initiative is an effort to support medical necessity and payment for billed radiology services and procedures by allowing MACs to request documentation, including but not limited to physician orders, physician notes, and inpatient facility progress notes, to facilitate their determinations.