0136-Medical Necessity and Coding of Chest X-rays

Submitted by Matthew.Gregor… on Mon, 11/04/2019 - 07:47
Issue Number - Name
0136-Medical Necessity and Coding of Chest X-rays
Review Type
Complex
Claim Type
Outpatient Hospital
Region and State
RAC 1-4
Date Approved
2019-01-08

Description

Radiographs of the chest are common tests performed in many outpatient offices (radiology and many others), clinics, outpatient hospital departments, inpatient hospital episodes, skilled nursing facilities, homes, and other settings. They can be used for many pulmonary diseases, cardiac diseases, infections and inflammatory diseases, chest and upper abdominal trauma situations, malignant and metastatic diseases, allergic and drug related diseases. This review will ensure chest x-rays are paid when billed appropriately and only when medically necessary.

Affected Codes

71045 – Radiologic Examination, chest-1 view 
71046 – Radiologic Examination, chest-2 views

71047 – Radiologic Examination, chest-3 views

71048 – Radiologic Examination, chest-4 or more views

Applicable Policy References

42 CFR, 411.15(a)(1) – Particular services excluded from coverage; Routine physical checkups
42 CFR, 486.100 - Condition for coverage: Compliance with Federal, State, and local laws and regulations
Social Security Act, Section 1862(a)(1)(A), §1862(a)(7) – Exclusions from coverage
Social Security Act, Section 1833(e) – Payment of benefits

CMS Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 80.4-80.4.4 
CMS Pub, 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 80.6.1, Definitions.
L37547 (Noridian – JE) Chest X-Ray Policy, Effective Date For services performed on or after 06/22/2018 
L37549 (Noridian – JF) Chest X-Ray Policy, Effective Date For services performed on or after 06/22/2018