Chest X-Ray Policy

Jurisdiction: JE Part B. States: California, Hawaii, Nevada, American Samoa, Guam, Northern Mariana Islands. Type: Active LCD

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. There are thousands of diagnoses which would constitute reasonable and necessary conditions for chest X-rays. Despite that, Noridian data shows that there are a large number of chest radiographs that do NOT appear reasonable and necessary. To simplify this policy, and for physicians to be reimbursed for chest X-rays and avoiding coding errors, we are converting this to a negative policy. Noridian is listing those diagnoses that are not reasonable and necessary based on literature from medical societies and clear community standards and for which the data analysis shows are the more common reasons for a denial. A chest X-ray that is not reasonable and necessary contributes to unneeded patient radiation exposure, patient anxiety, unnecessary visits to a medical or radiology facility, and increased costs to both patients and the Medicare Trust Fund. In general, preprocedural chest X-rays in the absence of symptomatic pulmonary or cardiac diseases, chest X-rays in the absence of signs or symptoms, and chest X-rays for minor trauma of the head, lower back or extremities are not reasonable and necessary. If a patient with known but stable, asymptomatic cardiac or pulmonary disease requires a chest X-ray, the reason(s) for the chest radiograph(s) must be clearly documented in the clinical chart with an explanation of how the results of the X-ray will be used for the patient's care. If a patient with known but stable, asymptomatic cardiac or pulmonary disease requires a pre-procedural chest X-ray, the reason(s) must be documented in the clinical chart with an explanation of how the results of the X-ray would be used for the patient’s care. Patients with symptomatic cardiac or pulmonary conditions (e.g., adverse change in cough, orthopnea, dyspnea on exertion, recent decrement in SaO2), planning surgery performed in ASC or outpatient facilities, the chart must document how the x-ray results will be used to make treatment decisions. Radiographs of the chest are commonly performed in outpatient offices (radiology and many others), clinics, outpatient hospital departments, inpatient hospital episodes, skilled nursing facilities, homes, and other settings. They are used to diagnose and aid in treatment decisions for pulmonary diseases, cardiac diseases, infections and inflammatory diseases, chest and upper abdominal trauma situations, malignant and metastatic diseases, allergic and drug related diseases. In general, preprocedural chest X-rays in the absence of pulmonary or cardiac diseases, chest X-rays in the absence of signs or symptoms, and chest X-rays for minor trauma of the head, lower back or extremities are not the current accepted medical practice.