Department  of  Health  and  Human  Services 
OFFICE  OF 
INSPECTOR  GENERAL 
MEDICARES  REIMBURSEMENT  FOR 
INTERPRETATIONS  OF  HOSPITAL 
EMERGENCY  ROOM  X-RAYS 
JULY 1993  OFFICE  OF  INSPECTOR  GENERAL 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 
amended, is to protect the integrity of the Department of Health and Human Services (HHS) 
programs as well as the health and welfare of beneficiaries served by those programs.  This 
statutorymissionis carried outthrougha nationwidenetworkof audits, investigations,and 
inspectionsconductedby three OIGoperatingcomponents: the Officeof AuditServices,the 
Officeof Investigations,andthe Officeof EvaluationandInspections. The OIGalsoinformsthe 
Secretary of HHS of program and managementproblems and recommendscourses to correct them. 
OFFICE  OF  AUDIT  SERVICES 
The OIGSOfficeof AuditServices(OAS)providesall auditingservicesfor HHS, either by 
conducting audits with its own audit resources or by overseeing audit work done by others.  Audits 
examine the performance of HHS programs and/or its grantees and contractors in carrying out 
their respectiveresponsibilitiesand are intendedto provideindependentassessmentsof HHS 
programs and operations in order to reduce waste, abuse, and mismanagementand to promote 
economy and efficiency throughout the Department. 
OFFICE  OF  INVESTIGATIONS 
The OIGSOfficeof Investigations(01) conductscriminal, civil, andadministrativeinvestigations 
of allegations of wrongdoing in HHS programs or to HHS beneficiaries and of unjust enrichment 
by providers.  The investigativeefforts of 01 lead to criminal convictions, administrative 
sanctions, or civil money penalties.  The 01 also oversees State Medicaid fraud control units which 
investigate and prosecute fraud and patient abuse in the Medicaid program. 
OFFICE  OF  EVALUATION  AND  INSPECTIONS 
The OIGSOfficeof Evaluationand Inspections(OEI)conductsshort-termmanagementand 
program evaluations(calledinspections)that focuson issuesof concernto the Department,the 
Congress, and the public.  The findings and recommendationscontained in these inspection reports 
generate rapid, accurate, and up-to-date information on the efficiency, vulnerability, and 
effectivenessof departmentalprograms.  Thisreportwaspreparedin the NewYork regionaloffice 
under the direction of Thomas F. Tully, Regional Inspector General and Alan S. Meyer, Deputy 
Regional Inspector General.  Project staff included: 
REGIONII  HEADQUARTERS 
Joseph J. Benkoski, Project Leader  Wm. Mark Krushat 
Joseph J. Corso, Jr,  Wayne A. Powell 
Lucille M. Cop, RN  Brian P. Ritchie 
William J. Counihan  Barbara R. Tedesco 
To obtain a copy of this report, call the New York Regional Office at (212) 264-1998  Department  of  Health  and  Human  Services 
OFFICE  OF 
INSPECTOR  GENERAL 
MEDICARES  REIMBURSEMENT  FOR 
INTERPRETATIONS  OF  HOSPITAL 
EMERGENCY  ROOM  X-RAYS 
JULY 1993  0EI-02-89-01490
 EXECUTIVE  SUMMARY 
PURPOSE 
To assess the appropriateness  of Medicare  policy permitting  reimbursement  for 
reinterpretations  of the same x-ray for emergency  room (ER) cases. 
BACKGROUND 
In a typical case,  an x-ray of a patient  treated  in an ER is interpreted  both by the treating 
physician  and by a radiologist.  The latter  reinterpretation  often takes place after the 
patient  is discharged. 
This inspection  evaluated  the Medicare  policy which allows payment  to each physician  for 
their  interpretations.  According  to Section 2020G of the Medicare  Carriers  Manual 
(MCM)  the service of the radiologist,  even if performed  after the patient  is discharged,
!1
... almost always constitutes  patient care and, thus,  would qualify as a physicians 
service.   Medicares  reasoning  is that the radiologists  reinterpretation  is a specialists 
evaluation  and could affect the course of treatment  initiated  or cause a new course of 
treatment  to begin. 
The inspection  consisted  of a review of 356 medical  records  and telephone  interviews  with 
ER and radiology  department  directors  at 18 hospitals  in nine States.  We also had 
discussions with directors  of residency  training  programs  in Emergency  Medicine  and with 
representatives  of Internal  Medicine  and Family  Practice  specialties regarding  training  in 
x-ray interpretations  in residency  programs. 
FINDINGS 
X-RAY REINTERPRETATIONS  BY RADIOLOGISTS  DID NOT CHANGE 
PRESCRIBED  TREATMENTS  BY EMERGENCY  ROOM PHYSICIANS 
We were able to identify  158 cases (44 percent)  in the sample of 356 cases where medical 
records clearly  indicate that radiologists  reinterpreted  x-rays at least one day after patients 
had been discharged.  We found that these reinterpretations  had no effect on the 
treatments  provided  by ER physicians.  No one among this group was recalled  for further 
evaluation  based upon the reinterpretations.  The experience  with these reinterpretations 
raises questions regarding  Medicares  policy assumption  that such a reinterpretation 
almost always constitutes  patient  care.  
Of the remaining  198 medical  records  in the sample,  only 22 contain clear documentation 
that interpretations  by radiologists  were made available to the ER physician  prior  to the 
patients  discharge.  In only one instance,  in this group of 198 cases,  was there 
documentation  that the ER physician  had specifically  requested  an interpretation  by a 
radiologist  before  determining  a plan of care;  this,  in fact,  was the only such request  among all 356 sample records.  The remaining  176 records do not document  whether  or 
not these interpretations  occurred before  or after patients were discharged.  However,  ER 
directors  at the  18 sample hospitals estimate,  that on the average,  three-quarters  of the 
interpretations  by radiologists  are performed  after patients  are discharged.  As was the 
case with interpretations  by radiologists  after patients had been discharged,  no one among 
this group was recalled  to the hospital or referred  elsewhere. 
MOST PHYSICIANS  WHO TREAT PATIENTS IN EMERGENCY  ROOMS  COME 
FROM THREE MEDICAL  SPECIALTIES;  THEY RECEIVE TRAINING  IN 
INTERPRETING  X-RAYS 
Physicians  specializing  in Emergency  Medicine,  Internal  Medicine  and Family  Practice 
represent  89 percent  of the ER physicians  in our sample.  The majority  of ER physicians 
(68 percent)  specialize  in Emergency  Medicine.  Physicians  specializing  in Internal 
Medicine  represent  11 percent  of sample cases; those in Family  Practice  represent  10 
percent. 
Physicians  specializing  in Emergency  Medicine  appear to receive  substantial  training  in 
x-ray interpretation.  We were informed  by several directors  of residency programs  in 
Emergency  Medicine  that training  in interpreting  x-rays is an integral part of their 
residency programs.  Physicians  specializing  in Internal  Medicine  and Family  Practice  also 
receive  training  in x-ray interpretation,  according  to representatives  of the Accreditation 
Council  for Graduate  Medical  Educations  Residency Review Committee  on Internal 
Medicine  and of the Board of Family  Practice. 
RECOMMENDATION 
In view of our finding that reinterpretations  of x-rays by radiologists  after patients  had 
been discharged  from emergency  rooms:  (1) did not result in the recall of patients;  (2) did 
not affect the course of treatment  initiated  or cause a new course of treatment  to begin; 
and (3) did not appear to constitute  patient care,  HCFA  should: 
Pay for reinterpretations  of x-rays only when attending  physicians  specifically 
request a second physicians  interpretation  in order to render appropriate 
medical care before the patient is discharged.  Any other reinterpretation  of 
the attending  physicians  original interpretation  should be treated  and 
reimbursed  as part of the hospitals  quality assurance program.  The HCFA 
should implement  this recommendation  through either regulation  or by seeking 
legislation  as appropriate. 
We project  that a minimum  of $20.4 million  was paid for reinterpretations  in 1990 for the 
38 sampled HCPCS  codes.  Our projection  does not take into consideration  the apparently 
infrequent  instances in which radiologists  interpretations  are specifically  requested  by the 
treating  physician  prior to treatment. 
ii  AGENCY  COMMENTS  AND OIG RESPONSE 
We received  comments  on this report  from HCFA.  We met with HCFA  staff to discuss 
their comments  and offer additional  information.  As a result,  HCFA  agreed to share 
copies of our draft report  with members  of the Technical  Advisory  Committee  on National 
Coverage  Issues which would consider the reports  recommendations  at its next quarterly 
meeting. 
The HCFA  noted that its current  policy on emergency  room x-rays is based on three 
assumptions:  (1) reinterpretations  almost always constitute  patient care;  (2) radiologists  are 
recognized  experts,  therefore,  x-rays should be read by them;  and (3) the qualifications  of 
the interpreting  physician  are more important  than the exact timing of the interpretation  in 
determining  whether  a substantive physician  service has been provided.  Our findings 
question all three assumptions  and are the basis for our recommendation  that a policy 
based on these assumptions be revised.  Based upon our finding that in no case did 
radiologists  interpretations  affect the course of treatment  by the ER physician,  we 
question whether  reinterpretations  almost always constitutes patient  care.   We also 
found that other physician  specialists believe they are qualified  to interpret  x-rays. 
In its comments,  the HCFA  also raised several concerns,  including  the medical  necessity 
of the services provided  to patients  in our sample and the sharing of radiologists 
interpretations  with attending physicians.  These concerns  and OIGS responses  are 
detailed  in an expanded  comments  and response  section in the report.  The complete  text 
of HCFAS comments  appears  in Appendix  A. 
... 
111  TABLE  OF  CONTENTS 
PAGE 
EXECUTIVE  SUMMARY 
INTRODUCTION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1

FINDINGS 
Reinterpretations  Of X-rays Did Not Affect  Patient  Care  . . . . . . . . . . . . . . .  5

Emergency  Room Physicians  Receive

X-ray Interpretation  Training..  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  6

RECOMMENDATIONS  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  7

Agency Comments AndOIGResponse  . . . . . . . . . . . . . . . . . . . . . . . . . .  7

APPENDICES

A: Comments  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..A-1

B: Projected  Savings  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..B-1

C: Confidence  Intervals For Savings Projections  . . . . . . . . . . . . . . . . . . . . .  C-1
 INTRODUCTION 
PURPOSE 
To assess the appropriateness  of Medicare  policy permitting  reimbursement  for 
reinterpretations  of the same x-ray for emergency  room (ER) cases. 
BACKGROUND 
An Emergency  Room  Visit 
An elderly  man,  while putting  his lawn mower away,  experienced  chest pains,  shortness 
of breath  and dizziness,  and fell heavily upon his left wrist.  He was driven by his wife to 
the emergency  room (ER) of the local hospital.  While there,  he was examined  by an ER 
physician  who ordered  an x-ray and other tests.  This physician,  upon review  of the x-ray 
film,  diagnosed  a simple fracture  and applied a splint.  Finding  everything  else normal,  he 
gave instructions  to the patient  and discharged  him. 
The following  day,  in keeping  with hospital policy,  a radiologist  reinterpreted  the x-ray 
film.  She prepared  a report  for the patients  medical  record confirming  the ER 
physicians  diagnosis.  Several days later,  this same patients  x-ray was selected for 
review by a second radiologist  as part of the hospitals  quality assurance program. 
How Medicare Pays 
The fictional  story above,  typical  of the manner  in which Medicare  patients  receive 
treatment  for injuries  in hospital emergency  rooms,  would have resulted  in the following 
claims actions. 
The ER physician  and the radiologist  who confirmed  the diagnosis would have submitted 
separate bills to a Medicare  carrier.  The radiologist  would be paid for her interpretation 
based on a radiology  fee schedule.  The ER physicians  bill for his services would not, 
however,  contain  a separate charge  for his x-ray interpretation.  This is because Medicare 
considers  its payment  for his interpretation  to be part of the attending physicians  overall 
workup and treatment  of the patient  (Medicare  Carrier  Manual  Section 2020G).  This 
same section does permit  payment  to the first radiologist,  stating that: 
... when a hospital  radiologist  interprets  an x-ray that has already been 
interpreted  by another physician,  that interpretive  service almost always 
constitutes  patient  care  ...  and the radiologists  findings could affect the 
course of treatment  initiated  or cause a new course of treatment  to begin. 
The fact that the particular  patient was not on the hospital premises  at the 
time the radiologist  interpreted  the x-ray is not controlling  in deciding 
whether  there was a physicians  service,  since the patient may be recalled. 
If on the other hand the radiologist  is interpreting  the x-ray for  quality  control  purposes  ... the service should be considered  a hospital  service 
reimbursable  under  Part A of the Medicare  program. 
The carrier  would have paid the ER physician  and the first radiologist  80 percent  of

Medicares  allowed charge.  Both physicians  would have billed the patient  for Medicares

20-percent  coinsurance  amount.

The hospital  would have sent its bill for providing  emergency  room services to a Medicare

intermediary.  These services include such items as salaries of employees,  facility

maintenance,  medical  supplies and equipment.  The intermediarys  payment  to the hospital

would cover the costs associated  with the services of the second radiologist.  These

services would be treated  as administrative  costs relating  to the hospitals  quality

assurance program.

How much Medicare  Pays 
In 1990, Medicare  allowed charges for all outpatient  department  (OPD) interpretations, 
including the ER, amounted  to $175 million.  Medicare  data does not separate charges  of 
radiologists  for interpretations  of ER x-rays from their charges  for other OPD 
interpretations.  The costs hospitals  incur for their quality  assurance programs  are not 
separately  identified  and are reimbursed  as a part of the reasonable  costs included  in OPD 
cost reports. 
Related Study 
A study of 23,500  x-rays,  conducted  from October  1984 to September  1985 at George 
Washington  University  Medical  Center,  evaluated  patient  care outcomes  in those instances 
where post-discharge  radiology  department  interpretations  differed  from ER physician 
interpretations.  As reported  in the Journal  of the American  Medical Association,  the 
study found an overall  error  rate of 1.8%  (424 patients)  in the accuracy  of ER 
interpretations.  There were no undesirable  patient  care outcomes  as characterized  by 
preventable  death,  permanent  loss of function,  suboptimal  restoration,  or prolonged 
recovery  identified  by delayed radiological  diagnosis. 
Medical Societies  Positions 
The policy of the American  College of Emergency  Physicians  is that emergency 
physicians  should initially  interpret  and record  the results of diagnostic  studies and tests 
they order for which they are trained  and competent  to interpret.  When appropriate,  such 
interpretations  should be made in consultation  with other specialists.  The College  notes 
that ER physicians  are entitled to charge and be reimbursed  for these services. 
The American  College  of Radiology  considers  the radiologist  responsible  for the 
radiological  services within the hospital.  This responsibility  cannot be delegated  to other 
physicians.  The College  feels that regardless  of when the interpretation  is available  to the 
2  attending physician,  the radiologists  interpretation  of previously  interpreted  ER x-rays 
constitutes  patient  care and is compensable  as a physician  service. 
METHODOLOGY 
The inspection  consisted  of a review of 356 medical  records  from 311 hospitals,  telephone 
interviews  with ER and radiology  department  directors  at 18 hospitals  in nine States and 
discussions with directors  of programs  offering  residency  training  in Emergency  Medicine. 
We also spoke with representatives  of Internal  Medicine  and Family  Practice  specialties 
regarding  training  in x-ray interpretations  in residency programs. 
This study examined  a random  sample of cases where Medicare  paid for interpretations  by 
radiologists  of x-rays on ER patients.  In this report,  these services are referred  to as 
reinterpretations,  when performed  after the patient  was discharged  from the ER.  The 
ER cases were identified  among all OPD claims by matching  ER visit codes with 38 codes 
for x-ray interpretations  occurring  within five days of the ER visit.  This time lapse match 
was established  based on preinspection  findings that interpretations  by radiologists 
frequently  occur after patients  are discharged.  The 38 procedures  cover  several anatomic 
sites: head and neck,  chest,  spine and pelvis,  and upper  and lower extremities.  Thirty-six 
of these diagnostic  procedures  deal with skeletal traumas;  the other two were x-rays of the 
chest which may or may not be related  to chest injuries.  The procedures  were chosen 
because they represent  x-rays commonly  taken in hospital  ERs.  We obtained 
reimbursement  data on the 38 codes in order to calculate  projected  savings. 
A multi-stage  sampling technique  was used.  The first stage of this sample used  1990 
BMAD data to randomly  select ten carriers,  with replacement,  proportionate  to the total 
number  of cases in each carrier.  The second stage originally  called for a minimum  of 30 
cases to be randomly  selected from each of the ten carriers  to assure adequate precision. 
However,  pre-inspection  data indicated  that oversampling  was necessary because many of 
the ER patients  would not have an outpatient  bill associated  with every physician  bill due 
to some ER patient  admissions  as inpatients.  Therefore,  based on our pre-inspection 
calculations,  73 cases were randomly  selected from each of the ten carriers  (730 total 
cases). 
Outpatient  records  were then obtained  from the  1990 Medicare  Automated  Data Retrieval 
System (MADRS)  for the ten sampled carriers.  These records enabled us to eliminate 
cases where the patient  had an inpatient  admission  immediately  following  the emergency 
room visit.  The 730 sample cases were then compared  to the MADRS data.  In order to 
allow for delays in billing  information  and billing errors,  we decided  that any outpatient 
department  bill with a date of service within three days of the ER physicians  bill was a 
valid match.  This comparison  reduced the sample to 452 cases which had a matching 
outpatient  department  bill within three days of the emergency  department  service.  These 
452 cases constituted  the study sample. 
We then requested  medical  records from the 311 hospitals where the x-rays were taken 
and received  404 records,  for an 89 percent  response rate.  We did not include 48 of the 
3  404 records  in the study because either the records were incomplete  (12) or the ER 
patients  (36) had been admitted  as inpatients.  Hospitals  also provided  the medical 
specialty of the attending  ER physician  for the sample cases. 
We abstracted  and reviewed  data from the remaining  356 medical  records.  This review 
included the frequency  of patients recalled  to the hospital based on radiologists 
reinterpretations  of x-rays and whether  subsequent evaluations  resulted  in changes in 
patients  courses of treatment. 
In a separate data collection  activity,  nine States with the largest number  of OPD x-ray 
interpretations  were identified.  A purposive  sample of 18 hospitals  (two in each State) 
based on bed size was selected and their ER and radiology  department  directors  were 
interviewed  by telephone.  Our discussions  in November  and December  1991 focused on 
(1) how often radiologists  interpret  x-rays before patients  are discharged  and how often 
after discharge,  and (2) the frequency  of recalling  discharged  patients  for further 
evaluation  based on these delayed reinterpretations  by radiologists. 
We wrote to the American  College  of Radiology  and the American  College  of Emergency 
Physicians,  asking them to designate  someone who could provide  their views on the 
respective  roles of ER and radiology  departments  in interpretation  of ER x-rays.  Neither 
organization  designated  a spokesperson,  but they did provide  their written positions. 
Lastly,  discussions  were held with directors  of five programs  offering  residency  training 
in Emergency  Medicine  and with representatives  of national  accreditation  organizations  for 
Internal  Medicine  and Family  Practice  specialties,  regarding  training  in x-ray 
interpretations  in residency  programs. 
4  FINDINGS 
X-RAY REINTERPRETATIONS  BY RADIOLOGISTS  DID NOT CHANGE 
PRESCRIBED  TREATMENTS  BY EMERGENCY  ROOM PHYSICIANS 
All Instances  Where Patients  Were Clearly Discharged  Before ReinterpretahonDo Not 
Appear  To Constitute P~ent  Care 
We identified  158 cases where medical  records  clearly  indicate that radiologists 
reinterpreted  x-rays after patients were discharged.  These reinterpretations  had no effect 
on the treatments  provided  by emergency  room physicians.  The medical  records  of these 
158 patients  (44 percent)  in the sample of 356 records,  document  that the reinterpretations 
of x-rays by radiologists  occurred  at least one day after patients  had been discharged.  No 
one among this group was recalled  to the hospital,  or referred  elsewhere,  for finther 
evaluation  of their condition  based upon the reinterpretations  by radiologists. 
The experience  with these reinterpretations  raises questions  regarding  Medicares  policy 
assumption  that such a reinterpretation  almost always constitutes  patient  care.   Our 
analysis is supported by the ER directors  at the 18 sample hospitals who estimate  that,  on 
the average,  less than two percent  of radiologists  reinterpretations  result in recall of 
patients  for further  evaluation  of the conditions  for which they sought care. 
Most Instances  Where Patients  Were Discharged  On The Same Day As  The 
Interpretation  Were Probably  Interpreted After Discharge And Appear Not  To Constitute 
Patient  Care 
Of the remaining  198 medical  records  in the sample,  only 22 contain clear documentation 
that interpretations  by radiologists  were made available  to the ER physician  prior  to the 
patients  discharge.  In only one instance,  in this group of 198 cases,  was there 
documentation  that the ER physician  had specifically  requested  an interpretation  by a 
radiologist  before determining  a plan of care;  this is the case with all 356 sample records. 
The remaining  176 records  indicate either that a radiologist  interpreted  x-rays on the same 
day of treatment  (160),  or the date of interpretation  was not recorded  (16).  There  is no 
indication  whether  or not these  176 interpretations  occurred  before  or after the patients 
were discharged.  However,  the ER directors  at the 18 sample hospitals estimate,  on the 
average,  that three-quarters  of all interpretations  by radiologists  are performed  after 
patients  are discharged.  This suggests that a majority  of these  176 interpretations  were 
probably  performed  post-discharge.  As was the case with interpretations  by radiologists 
clearly  documented  as having occurred  after patients  were discharged,  no one among this 
group of 176 patients  was recalled  to the hospital or referred  elsewhere. 
5  MOST PHYSICIANS  WHO TREAT PATIENTS IN EMERGENCY  ROOMS  COME 
FROM THREE MEDICAL  SPECIALTIES;  THEY RECEIVE TRAINING IN 
INTERPRETING  X-RAYS 
Physicians  specializing  in Emergency  Medicine,  Internal  Medicine  and Family  Practice 
represent  89 percent  of the ER physicians  in our sample.  The majority  of ER physicians 
(68 percent)  specialize  in Emergency  Medicine.  Physicians  specializing  in Internal 
Medicine  represent  11 percent  of sample cases; those specializing  in Family  Practice 
represent  10 percent. 
In response to our questions about the training  that physicians  in these three specialties 
received  in x-ray interpretation  in residency  programs,  we learned the following. 
Physicians  specializing  in Emergency  Medicine  appear to receive  substantial  training  in 
x-ray interpretation.  Directors  of five residency programs  in Emergency  Medicine 
reported  that training  in interpreting  x-rays is an integral part of their residency  programs. 
While each program  was not structured  in the same manner,  training  characteristically 
consisted  of working  in the radiology  department  for about a month,  reading  x-rays in the 
ER with trained  ER physicians  and attending  didactic  lectures  on radiology. 
Physicians  specializing  in Internal  Medicine  and Family  Practice  also receive training  in 
x-ray interpretation.  A representative  of the Accreditation  Council  for Graduate  Medical 
Education  indicated  that a typical residency  in Internal  Medicine  consists of a three-month 
assignment  to the ER in two- to four-week  blocks over the course of three years.  During 
these periods  training  in x-ray interpretation  is provided  by an experienced  ER physician. 
A representative  of the Board of Family  Practice  indicated that,  while each residency 
program  is different,  it provides  ample opportunity  to learn to read x-rays.  Some 
programs  have residents  assigned to the radiology  department  for varying  amounts of 
time. 
6  RECOMMENDATIONS 
In view of our finding that reinterpretations  of x-rays by radiologists  after patients  had 
been discharged  from emergency  rooms:  (1) did not result in the recall  of patients;  (2) did 
not affect the course of treatment  initiated  or cause a new course of treatment  to begin; 
and (3) did not appear to constitute  patient  care,  HCFA  should: 
Pay for reinterpretations  of x-rays only when attending  physicians  specifically 
request a second physicians  interpretation  in order to render appropriate 
medical care before the patient is discharged.  Any other reinterpretation  of 
the attending  physicians  original  interpretation  should be treated  and 
reimbursed  as part of the hospitals  quality assurance program.  The HCFA 
should implement  this recommendation  through  either regulation  or by seeking 
legislation  as appropriate. 
We project  that a minimum  of $20.4 million  was paid for reinterpretations  in 1990 for the 
38 sampled HCPCS  codes.  Our projection  does not take into consideration  the apparently 
infrequent  instances  in which radiologists  interpretations  are specifically  requested  by the 
treating  physician  prior  to treatment.  Nevertheless,  we consider  this to be a conservative 
estimate  due to (1) difficulties  in establishing  a universe  of ER x-ray interpretations  by 
radiologists  encountered  in drawing  our sample and (2) to the fact that our projection  is 
based on only 38 interpretation  codes.  It is probable  that substantially  more dollars  are 
involved.  During this same period Medicare  allowed charges for all outpatient  department 
interpretations,  including  the ER,  amounted  to $175 million. 
AGENCY  COMMENTS  AND OIG RESPONSE 
We received  comments  on this report  from HCFA.  We met with HCFA  staff to discuss 
their comments  and offer additional  information.  As a result,  HCFA  agreed to share 
copies of our draft report  with members  of the Technical  Advisory  Committee  on National 
Coverage  Issues which would consider  the reports  recommendations  at its next quarterly 
meeting.  A summary  of HCFAs  comments  and our response appears below.  The 
complete  text of HCFAs  comments  appears in Appendix  A. 
The HCFA  suggests that if x-rays were not medically  necessary  it would be unlikely  that 
either the ER physician  or the radiologist  would have identified  any medical problem 
when reading  the x-rays.  Our review of medical  records did not examine  the medical 
necessity of x-rays ordered  for ER patients.  Rather,  it focused on whether  radiologists 
interpretations  affected patient care;  in no instance did this occur regardless  of patients 
reasons for seeking medical  attention.  Our sample consisted of 164 cases (40 percent) 
covering  diagnostic procedures  of several anatomic  sites which normally  deal with skeletal 
traumas.  The remaining  212 cases (60 percent)  were chest x-rays of which 34 represented 
traumas.  Regarding  non-trauma  chest x-rays,  we reviewed  a subsample of 30 cases. 
7  Twenty-five  patients came to the ER with complaints  of chest pain.  The remaining  five 
patients  were seen for conditions  other than chest conditions;  one could question the 
necessity of these x-rays. 
The HCFAcomrnents  state that results of radiologists  interpretations  possibly were 
forwarded  to patients  attending  physicians  rather than to ER physicians.  While this may 
have been the case in some instances,  ourreview  ofrecords  compared  radiologists 
interpretations  with those of ER physicians.  The fact that results may have been sent to 
private  physicians  would not alter our comparative  analysis.  We found that radiologists 
interpretations  confirmed  those of ER physicians  in all cases. 
The HCFA  also noted that its current  policy  is based on three assumptions:  (1) 
reinterpretations  almost always constitute  patient care;  (2) radiologists  are recognized 
experts,  therefore,  x-rays should be read by them;  and (3) the qualifications  of the 
interpreting  physician  are more important  than the exact timing  of the interpretation  in 
determining  whether  a substantive physician  service has been provided.  Our findings 
question all three assumptions  and are the basis for our recommendation  that a policy 
based on these three assumptions  be revised.  Based upon our finding that in no case did 
radiologists  interpretations  affect the course of treatment  by the ER physician,  we 
question whether  reinterpretations  almost always constitutes  patient care.   We also 
found that other physician  specialists believe  they are qualified  to interpret  x-rays. 
The HCFA  notes that our recommendation  to limit coverage  of radiologists 
interpretations  to those performed  before  a patient  is discharged  would discriminate 
against small- and medium-sized  hospitals  which do not have radiologists  available  24 
hours a day.  We cannot respond directly  to this concern,  as we did not include the 
availability  of radiologists  in our study.  However,  we again note that no reinterpretations 
in our random  sample resulted  in a change in patient  care. 
The HCFA points out that it would be difficult  to enforce  our recommendation  on a 
prepayment  basis.  We note that HCFA has overcome  other prepayment  difficulties  by 
using such techniques  as code modifiers  and identification  of referring  physicians  for 
certain  services  in order to make coverage  determinations.  The HCFA  can also enforce 
this policy,  as it does many policies,  on a post-payment  basis using focused medical 
review, 
The HCFA  states that our savings estimate  appears to assume that Medicare  would not 
pay ER physicians  separately  for interpretations  if there were no payment  to radiologists. 
This is a correct  assumption.  Medicare  is currently  paying for ER physicians 
interpretations  as part of the total work-up  of the patient. 
8  APPENDIX  A 
COMMENTS  ON THE DRAFT REPORT 
A-1  .... 
Health  Care 
DEPARTMENT OF HEALTHZ?LHUMANSERVICES  Financing  Admmistfatlon
Memorandum 
w- .
Im  F
. 
/ 
i  am Toby,  Jr. 
Acting  Admkistrato~

Office  of Inspector  Gene.ml  (OIG)  Draft  Report:  kkdicares  Reirnbursem@  for

Interpretation  of Hospital  Emergenq  Room  X-ram  (OEI-02-8901490)

Bvan  B. Mitchell

P*@al  Deputy  Inspectrx  General

We  reviewed  the  draft  inspection  report  which  evaluates  the  appropriateness  of 
Medicare  reimbursement  for  radiologists  interpretations  of x-rays  which  have  been 
previously  interpreted  by hospital  emergenq  room  (ER)  physicians. 
OIG  recommends  that  the  Health  Care  Financing  Administration  (HmA)  pay 
for Teinterpretatinns  of x-rays  only when  the  ER  physician  specifically  requests  a 
second  physicians  interpretation  in order  to  render  appropriate  medical  care  to the 
patient  before  discharge.  Any other  reinterpretation  should  be  treated  ad 
reimbursed  as part  of the  hospitals  cpali~  assurance  program. 
HCFA  defers  comment  on the  recommendation  pending  OIG  clarification  of 
several  concerns  outlined  in the  attachment.  Once  this  information  is provided,  we 
will consider  presenting  OIGS findings  and  recommendation  to  the  HCFA  Technology 
Advisory  Committee  for their  evaluation  and  comment. 
Thank  ynu for the  oppcntuni~  to review  and  mrnrnent  on  this report. 
Attachment 
. 
., 
. 
dz?$
 Ctmnrnents  of the  Health  Care  Financing  Administration  fF?CFA)

on  the  Office  of Insuector  General  (OIGl  Draft

Audit  Reuort:  Medicares  Reimbursement  for

Interpretations  of HosDital  Emereencv  Room  X-ram

(OEI-02-89-0149Q

Recommendation  1 
HCFA  should  pay for  reinterpretations  of x-rays only when  attending  phyicians 
-W  =q~es  ~ *ti  physician!!  interpretation  in  order  to  render  appmpria$e 
medical  care  before  the  patient  is discharged.  Any other  reinterpretation  of the 
attending  physicians  original  interpretation  should  be  treated  and  reimbursed  as part  of 
the  hospitals  quality  assurance  program.  HCFA  should  implement  this  recommendation 
through  either  regulation  or by seeidng  legislation  as appropriate. 
HCFA  Resuonse 
HCFA  defers  comment  on  the  recommendation  pending  receipt  of DIG  dadicztion  ~f 
sewzral  &cmuems outlined  below 
o	 We  are  concerned  about  whether  all x-rays  ordered  for ER  patients  were 
medically  necessary.  It is not  clear  fkom  the  report  if OIG  considered  this 
factor.  If the  x-rays were  not  needed,  it is not  likely  that  either  the  ER 
physician  or the  radiologist  would  have  identified  any  medical  problem 
when  reading  the  x-rays.  (See  Coverage  Issues  Manual  section  50-28  for 
the  medical  necessity  guidelines  that  contractors  are  expected  to  apply-to 
diagnostic  procedures,  such as chest x-rays,  upon  admission  to  the  hospital.) 
o  Additionally,  it is not  clear  if OIG  examined  the  possibility  that  copies  of 
radiologists  written  interpretations  were  forwarded  to  the  patients 
attending  physicians  with  offices  outside  of the  hospital  (for  exarnpl% 
general  practice  physicians  or orthopedists)  rather  than  to  the  ER 
physicians  who  initially  treated  the  patient.  We  understand  that  many 
hosnitals  discourage  ER  patients  from  returning  to  those  facilities  to 
rec&ve  the  resulti-of  the~  x-rays  after  they  ha~  been  discharged  and  that 
many  radiologists  send  copies  of their  written  interpretations  directly  to  the 
attending  physicians  rather  than  the  ER  physicians. 
. . 
Upon  receipt  of this  additional  information,  we will consider  presenting  OKS  ~dings

and  recommendation  to  the  HCFA  Technology  Advisory  Committee  for  thefi  ewduation

and  comment.

Prior  to the  development  of the  current  policy in the  Medicare  Carrier  Manual  (MCM)

section  2020G,  Medicare  paid  for the  most  meaningful  x-ray interpretation

that  was  done  for ER  patients.  The  result  was  an administrative  nightmare  because  of
 Page  2 
the  various  competing  Nfedicaw  claims  for payment  and  the  difficulty  in deciding  which 
interpretation  Setices  were  reasonable  and  necessary  for the  patient. 
Currently,  MCM  section  2020G  provides  that  when a hospital  radiologist  interprets  an 
x-ray  that  has already  been  interpreted  by another  physic- that  interpretative  sewic.e 
almost  always  constitutes  patient  care  an~  thus, would  also  qual&  as a  physicians 
setice.  The  only situations  in which  a radiologists  interpretation  of an  ER  x-ray  is not 
covered  under  Medicare  is:  (1) where  the  ordering  of the x-ray  was not  medically 
necessary  in the  first  pl~  and  [2) where  the  patient  died  before  &  Merpnetation  was 
performed.  This  policy  is based  on the  assumption  that  it is the  radiologist  who  is the 
recognized  medical  expert  in reading  x-rays and  that  x-rays  appropriately  ordered  for  ER 
patients  should  be  read  by such  experts.  In addition,  our  current  policy  is based  on the 
assumption  that  the  qualifications  of the  interpreting  physician  are  more  important  than 
the  exact  timing  of the  interpretation  in determining  whether  a substantive  physician 
semice  has  been  provided  that  can  be  billed  separately  under  the  program. 
We  see  several  limitations  to  OIGS  recommendation.  If as OIG  sugges~  we limit 
coverage  of ~adiologists  x--y  interpretation  m &e  ER  &ming  to  those  performed  before 
patients  are  discharged,  such practice  would  discriminate  against  small- and  medium-s= 
hospitals.  Such  hospitals  do not  have  radiologists  available  .24 hcmrs a day ~  is the  +case 
at large  urban  hospitals. 
Additionally,  we would  like to  point  out  that  it would  be  difficult  to  enforce  OIGS 
recommended  policy  on  a prepayment  basis  since  the  information  required  to  make 
payment  (i.e., whether  the  interpretation  of the  x-ray was specifically  requested  by the 
ER  physician)  is not  captured  on the  physicians  billing  form.  Currently,  the  only way to 
determine  whether  the  ER  physician  requested  the  specialists  reinterpretation  is to  look 
at  the  medical  records. 
%nilarly,  the  issue  of bundling  electrocardiogram  interpretations  into  medical  visits was a 
policy  change  enacted  by the  OmniiUS  Budget  Reconciliation  Act  (OBRA)  of  1990. 
Given  the  controversy  about  that  provision,  particularly  the  disproportionate  effects  by 
specialty,  it is likely  to  be ?epeal~d  by Congress  It appears  highly doubtful  that  we 
would  have  much success in persuading  Congress  to  reenact  a similar  proposaL 
Lastly,  we are  concerned  with  OIGS savings  estimate  of $20 million.  It appears  that  this 
projection  assumes  that  Medicare  would  not  pay the  ER  physicians  for  interpretations  if 
there  were  no  payment  to  the  radiologist.  We  do not  believe  that  the  recommendation 
would  achieve  this  result  since  it does  not  appear  that  OIG  has  taken  into  account  the 
offsetting  costs  that  would  probably  result  from  the  demands  of ER  physicians  for  higher 
payments  for  their  interpretation  sewices.  It is highly probable  that  ER  physicians  would 
argue  that  they  dese~e  separate  coverage  and  payment  for  their  interpretation  semkes  if 
they,  rather  than  the  radiologists,  are  determined  to be  legally  responsl%le  to  the 
hospitals  and  patients  (as well as the  Medicare  program)  for providing  these  sefices.  APPENDIX  B 
PROJECTED  SAVINGS FOR 38 SAMPLED HCPCS CODES 
1990 Allowed OPD Amounts  1990 ER Savings 
Carrier-Sample  All X-Rays  Studied X-Rays  Projection 
FLORIDA  BS
 $11,023,700  $4,001,500  $1,344,378 
IOWA BS
 $1,933,100  $391,800  $189,173 
MICHIGAN  BS
 $8,339,200  $2,739,600  $973,721 
MASS BS FOR NH/VT
 $1,162,900  $219,100  $120,225 
PA BS FOR NJ
 $5,347,600  $1,859,800  $592,422 
PENN  BS-FIRST
 $15,040,300  $4,681,700  $1,734,855 
PENN BS-SECOND
 $15,040,300  $4,681,700  $1,515,649 
EQUITABLE  IDAHO
 $477,400  $129,200  $41,468 
NW OHIO-FIRST
 $9,422,100  $3,034,800  $1,322,389 
NW OHIO-SECOND
 $9,422,100  $3,034,800  $1,196,953 
National  Total  $174,953,900  $53,912,000  $20,371,162 
The projected  national  savings were calculated  using standard  statistical  formulas 
for a two-stage  cluster  sample and are not the sum of the  10 samples from the 
carriers. 
B-1  APPENDIX  C 
CONFIDENCE  INTERVALS FOR 
SAVINGS PROJECTIONS  $20,371,162 
90 % Confidence Interval  Precision  8.16% 
Lower  $18,708,726 
Upper  $22,033,599 
95 % Confidence  Interval  Precision  9.72% 
Lower  $18,390,387 
c-1