As a condition of fee schedule payment, services are required to contribute directly to the diagnosis or treatment of an individual beneficiary.5 When Medicare Administrative Contractors (MAC) receive a single claim for interpretation and report, “they must presume that the one service billed was a service to the individual beneficiary rather than a quality control measure …”60
However, when a MAC receive[s] multiple claims for the same interpretation “[MACs must] pay for the interpretation and report that directly contributed to the diagnosis and treatment of the individual patient.” The Medicare Claims Processing Manual does not require contractors to confirm that interpretations were performed at the same time that the patient was in the emergency department or that the interpretation contributed to the diagnosis and treatment of the individual beneficiary when a single claim is submitted.
7 The Medicare Claims Processing Manual goes on to state that MACs must “pay for the interpretation billed by the . . . radiologist if the interpretation of the procedure is performed at the same time as the diagnosis and treatment of the beneficiary.” Any other reinterpretation of the original interpretation (e.g., one that was performed after the beneficiary has left the emergency department) should be treated and reimbursed through the diagnosis-related group as part of the hospital’s quality assurance program.8
Medicare payments for diagnostic radiology services in hospital outpatient emergency departments have two components: a technical component,9 paid by Part A; and a professional component, paid by Part B. This report addresses only the professional component, which includes payments for physicians’ interpretations of images and reports on the clinical findings for inclusion in beneficiaries’ hospital-maintained medical records.10 Payments for the professional component are sent to interpreting physicians (i.e., emergency room physicians or radiologists).11
After diagnostic radiology services are ordered by emergency department physicians, they can:
• review diagnostic radiology images as part of evaluation and management (E/M) services for beneficiaries,12
• perform interpretation and reports of diagnostic radiology services, and/or
• consult with radiologists for their interpretation and reports on the findings for diagnostic radiology services.13
Claims submitted for interpretations without complete written reports do not meet the conditions for payment.
Both emergency department physicians and radiologists may be paid for their interpretation and reports for CTs, MRIs, or x-rays.
14 Medicare generally pays for only one interpretation and report for each diagnostic radiology service furnished to an emergency department patient.15