Diagnostic Mammography

Insufficient Documentation Causes Most Improper Payments. Insufficient documentation means that something was missing from the medical records. Below is a list of the most common reasons CERT determined there was insufficient documentation that caused improper payments for diagnostic mammogram.

• • Missing the authenticated physician order
  • Missing the documentation to support the medical need for the diagnostic mammogram
  • Missing the authenticated radiology report

Physicians order: Must be signed, dated, and indicate if unilateral or bilateral.

Supportive Documentation: The signed physician progress note that should indicate one of the following conditions. A patient has distinct signs and symptoms for which a mammogram is indicated; patient has a history of breast cancer; or patient is asymptomatic but, on the basis of the patient’s history and other factors the physician considers significant, the physician’s judgment is that a mammogram is appropriate.

Radiology Report: Must be signed and dated by the physician.

Related Content

• • Centers for Medicare & Medicaid Services Internet-Only Manual, Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Section 220.4 (Mammograms)
  • CMS IOM Publication 100-04, Medicare Claims Processing Manual,
    • Chapter 1, Section 110.1 (C) (Medical Record Material)
    • Chapter 13, Section 20.2 (B) (Payment for Radiology Services Technical Component)
    • Chapter 18, Section 20 (B) (Diagnostic Mammography)
  • CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.2 (Reasonable and Necessary Criteria)