Medical Necessity in Radiology
As the scrutiny of proving medical necessity for X-rays has increased, the volume of patient cases that meet the standard for medically necessary films has drastically decreased.
It used to be common practice for a Chiropractor to take X-rays to support their Report of Findings presentation, or even for patient education. However, these no longer suffice as specific or valid reasons to expose a patient to ionizing radiation. It may also seem rational for a Chiropractor to take films to see exactly what it is they are adjusting; however, that does not constitute as a medically necessary reason to do so then bill a third-party payor.
So, what is a justifiable rationale for films?
There are many symptoms and findings a patient may present with that do support medical necessity, but for simplifying this decision-making process, we will condense it to the 3 main (or most important) rationales:
- Recent trauma to the area in question
- Red flags for infection or carcinoma (especially prior or family history), and
- A scoliosis evaluation (when presented with clinical indicators)
Additionally, there may be times when medical necessity supports more than a simple X-ray. If a patient presents with symptoms that would support the referral for more diagnostic imaging, such as an MRI, be certain the symptoms meet at least one of the following indicators:
- Lingering pain (beyond 4 weeks)
- Worsening neurological symptoms which seem to be progressing
- Suspected fracture that is not visible on plain films
It is important to clearly document the need for films in the patient record and to include the written radiology report. Remember that, in the eyes of a payor, no written report in a patient record equals no medical necessity.
If films are deemed not medically necessary, be sure to document it in the patient record. It is to your advantage to document this to demonstrate that, not only to show that a thorough examination been performed, but that the patient’s condition was such that films were unnecessary at that time. This may further support the need for films later should the patient’s condition worsen. Looking for a simple and easy to use x-ray report? The Paperwork Project has you covered! Click here to download your FREE x-ray report form!