1) To determine the extent Medicare allowed claims for interpretation
and reports of diagnostic radiology services focusing on Computed
Tomography (CT), Magnetic Resonance Imaging (MRI), and X-ray services
performed in hospital outpatient emergency departments met Medicare
documentation requirements;
2) To determine if the X-ray services were performed before
beneficiaries left the hospital outpatient emergency departments; and
3) To determine if X-ray services followed suggested documentation
practive guidelines promted by the American College of Radiology.
Providers have a vital role when completing the documentation to support
claims for payment for Diagnostic Radiology Services. The key elements
of the medical record documentation should include (1) physicians orders
to support diagnostic radiology services performed and (2) complete
interpretation and reports.
The study completed by the OIG included two populations from 2008 claims
datasets, i.e., a sample of 220 CT and MRI claims and a sample of 220
X-ray claims. The standards the OIG used during the audit to determine
incorrect claims from the sample were as follows:
1) Documentation did not support that services were performed;
2) Physicians orders were not present; and
3) All interpretation and reports showed the services were performed
during beneficiaries’ diagnoses and treatments in the hospital
outpatient Emergency Departments.
The OIG used the American College of Radiology’s suggested documentation
practice guidelines as a guidance document during the review.
OIG Findings
The study found that in 2008:
1. 19 percent of CTs and billed MRIs and 14 percent of billed X-rays in
hospital outpatient emergency departments were not in compliance with
Medicare requirements because of insufficient documentation.
2. Medicare paid for interpretation and reports percent of X-rays and 12
percent of CTs and MRIs after beneficiaries left hospital outpatient
emergency departments and that Centers for Medicare and Medicaid
Services (CMS) offers inconsistent payment guidance on the timing for
interpretation.
3. 71 percent of X-rays and 69 percent of CTs and MRIs in hospital
outpatient emergency departments did not follow one or more suggested
documentation practice guidelines promoted by the American College of
Radiology.
CMS concurred with the first and third finding above. However, with
regard to the second recommendation, CMS indicated that it does not
believe that a single billed interpretation must, in all cases, exist
with the beneficiary’s diagnosis and treatment to contribute to that
diagnosis and treatment. A uniform policy requiring that interpretation
and reports be contemporaneous with, or, if not contemporaneous,
demonstrably contribute to the beneficiary’s diagnosis and treatment
could reduce unexplained complexity in what is already a complicated
billing system for medical diagnostics.
The Key Points section below reviews Medicare policy for coverage of
diagnostic radiology services in emergency departments and includes a
link to the suggested practice guidelines from the American College of
Radiology.
Key Points
• The professional component of a diagnostic procedure furnished to a
beneficiary in a hospital included an interpretation and written report
for inclusion in the beneficiary’s medical record maintained by the
hospital.
• Medicare Carriers and MACs generally distinguish between and
“interpretation and report” of an EKG procedure and a “review” of the
procedure. A professional component billing based on a review of the
findings of the procedures, without a complete, written report similar
to that which would be prepared by a specialist in the field, does not
meet the conditions for separate payment of the service.
• Medicare Carriers and MACs pay for only one interpretation of an
EKG or X-ray procedure furnished to an emergency room patient. They pay
for a second interpretation (which may be identified through the use of
modifier – “77”) only under unusual circumstances (for which
documentation is provided) such as a questionable finding for which the
physician performing the initial interpretation believes another
physician’s expertise is needed or changed diagnosis resulting from a
second interpretation of the results of the procedure.
• When Medicare Carriers or MACs receive multiple claims for the same
interpretation, they must generally pay for the first bill received.
They must pay for the interpretation and report that directly
contributed to the diagnosis and treatment of the individual patient.
• The physician specialty isn’t a primary factor during the claims decision process/cycle.
