The radiologist's paradox

Executive summary

In late March 2026, the American College of Radiology and the Radiology Business Management Association formally raised an operational issue that has been building inside diagnostic imaging for years. Noridian Healthcare Solutions placed the professional component of CPT 74177 and CPT 72148 under prepayment review through the Targeted Probe and Educate program. [1] [2]

The burden lands on radiology groups whose radiologists do not control the referring record requested to establish medical necessity. When supporting documentation is incomplete, claims are denied; sustained denial rates can trigger CMS escalation paths.

This paper has two parts: Part 1 states the current regulatory and industry facts from primary sources; Part 2 offers a forward operational view for imaging groups building resilience under sustained documentation scrutiny.

Part 1. The Now

The ACR and RBMA position

On 26 March 2026, ACR announced support for a joint ACR and RBMA request asking Noridian to exempt the professional component of CPT 74177 and CPT 72148 from TPE prepayment review. [1] [2]

Their argument is operational: hospital-based radiologists interpreting studies generally do not control source documentation required to justify medical necessity, yet they bear immediate denial exposure.

Noridian, TPE, and the MAC landscape

Noridian serves as MAC for Jurisdictions E and F. [3] Under TPE, selected services can be placed into up to three rounds of prepayment review with education between rounds; continued high denial performance may then be referred to CMS for additional actions. [4]

The federal documentation standard

Section 1862(a)(1)(A) of the Social Security Act limits payment to items and services that are reasonable and necessary. [5]

42 CFR 410.32 governs diagnostic test coverage conditions, including ordering requirements tied to the treating physician standard. The time-of-order documentation expectation was further established in BBA 1997 Section 4317(b). [6]

CMS guidance (MLN909160, October 2024) identifies incomplete progress notes and missing intent-to-order documentation as recurring causes of improper payment findings. [7]

What CERT measures

CERT uses statistically valid annual claim sampling to measure compliance with Medicare FFS coverage, coding, and payment rules. For FY 2024, CMS reported a 7.66% improper payment rate, representing $31.70 billion. [8] [9]

What MACs identify as common documentation errors

Noridian's JF Part B CERT common-error categories include imaging claims with:

• Missing physician order or intent only
• Missing physician order or intent and supportive documentation
• Missing results or report only
• Missing supportive documentation

These categories frame how imaging documentation defects are operationalized during local CERT and related review activity. [10]

Peer-reviewed evidence on imaging order data

Hanna et al. (Emory, 2017) found incomplete clinical documentation at interpretation time in 33.4% of cases, with a subset of CT and ultrasound exams completed before provider notes began. [11]

Rousseau et al. (Brigham and Women's, 2019) found HPI documentation completed before order entry in 23.1% of headache CT encounters and concept mismatch between notes and requisitions in 92.9% of those cases. [12]

What these facts describe together

• Federal standards assign documentation responsibility upstream at order time.
• CMS continues to identify insufficient documentation as a top improper-payment driver.
• MAC-level error categories repeatedly surface missing orders and supportive records.
• Peer-reviewed ED evidence shows frequent timing and content gaps between notes and orders.
• ACR and RBMA have formally identified burden on hospital-based radiologists who do not own those records.

Part 2. The Future

Where operational infrastructure for imaging groups is heading

The forward posture now developing in diagnostic imaging is infrastructure-first: building upstream controls that capture, validate, and preserve documentation context before the claim is exposed.

Why this direction, and why now

Regulatory review pressure is not contracting. TPE is national, and targeted codes or jurisdictions rotate over time.

The federal standard itself has remained stable. What changed is operational feasibility: modern data exchange and NLP pipelines now make context capture and retrieval practical at scale.

What this means for imaging group executives

The emerging operating model treats order intake as infrastructure, not clerical overhead. In this model, by the time billing submits a claim, the supporting record is already complete and auditable.

ACR and RBMA advocacy addresses immediate exposure for specific codes in specific jurisdictions. The durable strategic response remains local: each group's operational ability to produce complete records under scrutiny while protecting radiologist capacity.

References