Failure to obtain proper prior authorization is one of the key reasons for claim denials in many medical specialties and radiology is not an exception. Whether you are an imaging specialist or a referring physician, prior authorization from the insurer helps to ensure that patients can undergo the procedures they need in a timely manner. Radiology prior authorization services are now available so that radiology practices do not have to spend their time obtaining pre-authorizations and following up with clinical documentation.

Before rendering the service, the radiologist must verify that prior authorization was obtained. Payments are denied for procedures performed without the required authorization.

Radiology exams that may require pre-authorization include:

  • Bone Mineral Density exams ordered more frequently than every 23 months
  • CT scans (all diagnostic examinations)
  • MRI/MRA (all examinations)
  • Nuclear cardiology
  • PET scans
  • Stress echo cardiograms

The process for authorization must begin at the time of the patient’s registration for an appointment. The front office staff must gather as much information as possible about the patient’s condition and the reasons for the exam. All details are important, as it may be necessary for the radiology department or imaging center staff to contact the referring physician’s office. Also, the staff should verify that imaging orders are appropriate and complete. In some cases, it can be seen that the referring office will have obtained an authorization from the insurance company.

Accurate Codes as Crucial as Authorization

Along with prior approval, it is also important that specific procedure and diagnosis codes are reported in the claim for it to be processed correctly. CPT coding updates in radiology for 2019 has brought many new codes and deleted some. New codes that were added include:

    • 77046 MRI Breast, without contrast, unilateral (deleted code 77058)
    • 77047 MRI Breast, without contrast, bilateral (deleted code 77059)
    • 77048 MRI Breast, without and with contrast, unilateral (deleted code 77058)
    • 77049 MRI Breast, without and with contrast, bilateral (deleted code 77059)
    • 76978 Targeted dynamic microbubble sonographic contrast characterization (non-cardiac); initial lesion
    • 76979 (Add-on) Each additional lesion with separate injection
    • 76981 Elastography, parenchyma (e.g., organ)
    • 76982 Elastography; first target lesion
    • 76983 (Add-on) Each additional target lesion, not to be used more than two times per organ

ICD-10 codes related to imaging procedures include:

    • R93.421 Abnormal radiologic findings on diagnostic imaging of right kidney
    • R94.02 Abnormal brain scan
    • R94.11 Abnormal results of function studies of eye
    • Z12.3 Encounter for screening for malignant neoplasm of breast
    • Z12.4 Encounter for screening for malignant neoplasm of cervix

Once the authorization is obtained, your practice must verify that the approval matches the exam to be performed, including the date of service since authorizations can expire. In case of any delay in obtaining authorization, the appointment should be rescheduled to avoid denial. Appointment scheduling services should be perfect to avoid patient dissatisfaction and payment delays.

Any changes to the procedure actually ordered should also be communicated to the insurance company so that the procedure codes ultimately sent in on the claim form match the payer’s authorization records. Results of the authorization process should be monitored to make sure that the claims are paid as timely and accurately as possible.

To avoiding payment denials due to failure to obtain proper authorization, radiology practices can train their registration staff to gather as much detailed insurance information as possible from patients, make them aware of which procedures require prior authorizations and forward appointments for those procedures to the dedicated authorization staff, ask them to obtain or verify authorizations when they are required and reschedule patient appointments when needed, and advise them to notify the authorization staff of any changes that occur if the actual exam performed is different from the one authorized.

Authorization Guidelines from NIA

Based on the clinical guidelines from NIA (National Imaging Associates),

    • Only one authorization request is required for Abd/Pelvis CTA & Lower Extremity CTA, using CPT Code 75635 Abdominal Arteries CTA
    • For Abdomen/Pelvis MRA & Lower Extremity MRA Runoff Requests, two authorization requests are required – one Abd MRA, CPT code 74185 and one for Lower Extremity MRA, CPT code 73725
    • An authorization for MRI in addition to MRA is not required, as a request for MR Angiography includes standard MRI imaging
    • A single authorization for CPT codes 70486, 70487, 70488, or 76380 includes imaging of the entire maxillofacial area including face and sinuses. Multiple authorizations are not required.
    • A single authorization for CPT code 70540, 70542, or 70543 includes imaging of the Orbit, Face, Sinuses, and Neck. Multiple authorizations are not required.

As the pre-authorization process can be very time-consuming, requiring constant follow-up by the radiology office, it is more practical to outsource the task. Professional medical billing companies will be up to date with the changing insurance authorization requirements, when scheduling patients for radiology exams. Skilled Prior Authorization Coordinators in such companies will call insurance companies and get authorizations in the most efficient manner. Authorization specialists will verify that the documentation is complete and will then coordinate the authorization approval with the insurer.