HAP Radiology Billing and Coding Blog

The Need for Standardized Radiology Documentation to Maximize Medicare Reimbursements

Posted: By HAP USA on March 10, 2017

radiologu documenationAccuracy and completeness in radiology reporting has taken on an even higher level of importance in order to maximize Medicare reimbursement. The Quality Payment Program (QPP) under MACRA highlights the necessity to meet new quality performance standards.  While the benefits of structured reporting using templates have been discussed before, including in our article Reimbursement Benefits of Structured Radiology Reporting, reporting on quality measures under the QPP has to include very specific terminology in order to receive credit for the measure.  This is an ideal time for radiologists to begin to use standardized reporting across their practice to ensure that all of the critical elements of documentation are met. 

Templates Assist with Proper Coding

The QPP has many of the same requirements as the PQRS program had, so we can apply the lessons learned over recent years. For example, PQRS measure 145 requires that either a) the radiation exposure indices, or b) the exposure time and number of fluoroscopic images, be included in the documentation in order to obtain credit for accurately reporting the measure.  Building either of these elements into a reporting template is a good idea because it will not allow the radiologist to inadvertently omit this critical data.  Making the number of images, for example, a required field that will only accept a numerical answer will avoid the mistake of dictating a word for the number of images, which is unacceptable under CMS guidelines.


Another example from PQRS is measure 195, which requires the reporting of a measurement of the carotid siphon/terminus. Reporting “no stenosis” will not count, as a numerical answer is required for CMS.  A template with a number field for “% stenosis” will require a digital zero character to be entered and the measure will then be satisfied. 

Incidental Findings

Radiologists typically mention incidental findings that may or may not be significant. In an effort to curb unnecessary follow-up procedures, Medicare designed PQRS measures 405 and 406 to determine if incidental findings that are highly likely to be benign are receiving follow-up imaging routinely.


Measure 405 applies to all abdominal imaging studies of asymptomatic patients using CT, MRI or ultrasound.  When lesions are found incidentally, the documentation for these exams should clearly indicate specific values for the following, as applicable:

  • Liver lesion __ cm
  • Cystic kidney lesion __ cm
  • Adrenal lesion __ cm

In addition, the radiologist’s recommendation should contain standard language such as this example for an incidental liver lesion:

“In the absence of any known increased hepatic risk factors, hepatic dysfunction, or known primary malignancy, this finding is statistically most likely benign and therefore no further follow-up would be considered necessary considering the above caveats.”

This information will allow coders to easily apply the proper coding defined in the measure specifications and it will support compliance with the measure in case of a CMS audit.


Measure 406 applies to CT or MRI of the chest or neck, or ultrasound of the neck, for patients who have no known thyroid disease. When a nodule is noted incidentally, the documentation should clearly state the size of the nodule and the radiologist’s recommendation for follow-up imaging, if any. 


Successful participation by radiologists in MIPS will require a high level of achievement in the Quality Performance category.  By applying the experience gained through the now-defunct PQRS program, proper documentation through the use of standardized reporting templates will help practices maximize reimbursement under this new program. 


Our series of articles about MIPS will help practices understand its complex set of rules, many of which will continue to evolve. While radiologists might achieve exemption from the Advancing Care Information category and an easier level of reporting in the Improvement Activities category, the Quality Performance category will remain as the primary determinant of the MIPS final score.  Be sure to subscribe to our blog to receive our latest coverage of the QPP/MIPS and its impact on radiology practices.


Related articles:
Transitioning Your Radiology Practice to MIPS: Improvement Activities
Why the MIPS Patient-Facing Rules are Important to Radiologists
Transitioning Your Radiology Practice to MIPS: The Quality Component Updated


Download the whitepaper: "5 Potential Revenue Leaks in Your Radiology Practice"



Topics: radiology reimbursement, medicare reimbursement, MIPS, MACRA

Subscribe to our radiology billing and coding blog

Recent Posts


How a radiology practice recovered lost referrals