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A single scan can produce two billable services under one order. We code the professional and technical sides correctly, keep pace with authorization rules that change by payer, and recover the claims a busy imaging group doesn’t have time to chase.
A radiology group can read several hundred studies in a day, each one a small dollar amount on its own. The rules for imaging claims also differ from an office visit: two components, payer-specific authorization, and coding that changes by contrast, technique and body region.
When a patient gets two imaging studies in one session, Medicare reduces the technical component of the second one by half. Missing that adjustment either underpays the group or creates an overpayment a payer later recoups.
Teleradiology means the physician reading the study and the patient having it done are often in different states, which raises questions about licensure, the right NPI, and how the claim should be coded for that setting.
A facility furnishing the technical component of MRI, CT or PET in a non-hospital setting has to hold current accreditation from a body CMS recognizes, or Medicare won't pay that part of the claim at all.
The two use different codes and different cost-sharing rules for the patient. Coding a diagnostic follow-up as a screening exam, or the reverse, creates a payer correction and an unhappy patient bill.
Catheters, wires and embolization material used during an image-guided procedure are usually bundled into the procedure code, not billed as separate line items.
A covering radiologist reading overnight or during a partner's absence bills under the substitute-physician rules, not simply under the group's usual biller of record.
A radiologist reading studies for facilities in several states needs an active license, and often a separate payer enrollment, in each one.
Most radiology denials trace back to a short list of repeat mistakes. None of them are complicated once you see the pattern, but at high volume they add up fast.
Payment reduction skipped. The technical component on the second same-session study gets billed at full value instead of the reduced rate, and the overpayment gets clawed back later.
Wrong site-of-service code. A study read for a freestanding center gets billed with a hospital-based place-of-service code, which changes the allowed amount and can trigger a payer review.
Screening billed as diagnostic. A routine screening mammogram coded as diagnostic removes the patient's no-cost-sharing protection and can draw a payer audit.
Substitute reads under the wrong NPI. An overnight or vacation-coverage read gets submitted under the primary radiologist instead of the correct substitute-physician modifier.
Authorization confirmed for the wrong CPT. The RBM approves one imaging code, but the study performed uses a different one, and the mismatch denies the claim even though authorization exists.
Interventional supplies unbundled. Catheters and embolic material get billed as separate lines when the payer's edits say they belong inside the procedure code.
Imaging CPT codes are specific to modality, region, contrast and, for some studies, whether more than one body area was scanned in the same session.
For illustration. The correct code depends on the modality, region, contrast and technique documented in the report.
The reason on the order has to match the study's medical necessity policy for that payer.
Most MRI, CT, PET and nuclear studies route through a radiology benefit manager before they happen. Which vendor a payer uses, and what that vendor requires, varies by plan.
Uses a peer-to-peer, education-first review model for advanced imaging and works with payers including Humana in several markets.
An affiliate of Magellan Health that manages non-emergent outpatient imaging authorization for a number of Medicaid managed-care and commercial plans.
A newer AI-assisted platform that several large payers, including Humana, now use for diagnostic imaging authorization and real-time decisioning.
A facility furnishing the technical component of MRI, CT or PET outside a hospital has to hold current accreditation from a CMS-recognized body such as the American College of Radiology, the Joint Commission or the Intersocietal Accreditation Commission. Without it, Medicare denies that part of the claim regardless of how the study was coded.
Every facility performing mammography, screening or diagnostic, needs current certification under the Mammography Quality Standards Act, with equipment and staffing reviewed on a recurring basis. A lapsed certification stops reimbursement for the technical component even if the read itself was correct.
Most imaging denials are decided before the study even happens. Once the exam is done, the work is disciplined follow-through.
Eligibility, benefits and the correct CPT-specific authorization checked before the appointment.
Every completed study captured from RIS and PACS, so nothing gets read and never billed.
Component, contrast, bundling and payment-reduction rules applied to match what the report documents.
Claims scrubbed against payer edits before they go out, not after a denial comes back.
Denials worked by root cause, with the report and order attached to support each appeal.
Payments posted and matched line by line against the fee schedule, and AR followed until it's resolved.
Whether your radiologists read on-site, cover overnight from another state, or split professional and technical billing with a separate facility, we build the workflow around that arrangement instead of a generic template.
Same-session bundling and technical-component reductions applied at the coding stage, not caught later in an audit.
HealthHelp, National Imaging Associates and Cohere Health, plus which payers now exempt high-performing providers from routine review.
State licenses, payer enrollment and accreditation status monitored for every location and every covering radiologist.
Denial reasons by CT, MRI, ultrasound and nuclear medicine, not just a single number for the whole group.
If payment reductions, authorization delays or coding mismatches are quietly cutting into collections, we'll walk through your current process and point to exactly where the revenue is going.
