Department of Health and Human Services
 
OFFICE OF 

 
INSPECTOR GENERAL 

 
 
 
 
 
 
 
 
 
G A I
ROWTH IN  DVANCED  MAGING 

P U M
AID  NDER THE  EDICARE 

P F S  
HYSICIAN  EE  CHEDULE 

 
Daniel R. Levinson 
  
Inspector General 

 
October 2007 
 
OEI-01-06-00260 
   
Office of Inspector General 

 
http://oig.hhs.gov 
 
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 statutory mission  is  carried  out through  a nationwide network  of  audits, 
investigations, and inspections conducted by the  following operating components:  
Office of Audit Services 
The Office of Audit Services (OAS) provides all auditing services  for 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 respective responsibilities and are intended  to provide independent  
assessments of  HHS programs and operations.  These assessments help reduce waste, 
abuse, and mismanagement  and  promote economy and  efficiency throughout HHS. 
Office of Evaluation and Inspections  
The Office  of  Evaluation and Inspections (OEI)  conducts national evaluations to  provide 
HHS, Congress, and the public with timely, useful, and reliable information on 
significant issues.  Specifically, these evaluations focus on preventing fraud,  waste,  or  
abuse and promoting  economy, efficiency, and effectiveness  in departmental programs.  
To promote impact, the reports also present practical recommendations for improving 
program operations.  
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative  
investigations  of  allegations of wrongdoing  in HHS  programs or to HHS  beneficiaries  
and of unjust enrichment by  providers.  The investigative  efforts  of OI lead to  criminal  
convictions, administrative sanctions,  or  civil monetary penalties.  
Office of Counsel to the Inspector General 
The  Office of Counsel to the Inspector General (OCIG)  provides  general legal services  to  
OIG, rendering  advice and opinions on HHS programs  and operations and providing all 
legal support in OIG's internal operations.   OCIG imposes program exclusions and civil 
monetary penalties  on health care providers and litigates  those actions  within HHS.   
OCIG also  represents OIG in the global settlement of  cases  arising under the Civil False 
Claims Act, develops and monitors corporate integrity agreements, develops compliance 
program guidances, renders advisory opinions on OIG sanctions to  the health care  
community,  and issues fraud alerts  and other industry  guidance.  
    E X E C U T I V E   S U M M A R Y  
OBJECTIVE 
To determine the extent and nature of growth in advanced imaging 
paid under the Medicare Physician Fee Schedule from 1995 to 2005. 
BACKGROUND 
Advanced imaging used to be the exclusive domain of hospitals; 
however, in the last 10 to 15 years, the Medicare program has seen  
the use of these servicesmagnetic resonance (MR), computed  
tomography (CT), and positron emission tomography (PET) 
proliferate in ambulatory settings. 
The main Medicare payment systems for advanced imaging in 
ambulatory settings are the Medicare Physician  Fee Schedule (MPFS) 
and the Hospital Outpatient Prospective Payment System (OPPS).  In 
general, the MPFS pays for services  provided by noninstitutional 
providers, such as doctors and independent diagnostic testing 
facilities (IDTF), while the OPPS  pays for services provided in 
hospital outpatient departments.  
Oversight of ambulatory settings that provide advanced imaging 
includes accreditation and certification for hospital outpatient 
departments and State licensure for IDTFs and doctors offices.  
IDTFs must also meet basic standards to enroll in Medicare. 
A 2006 Office of Inspector General (OIG) review of IDTFs found 
substantial noncompliance with Medicare standards and 
recommended that CMS consider conducting site visits of IDTFs. In 
response, the Centers for Medicare & Medicaid Services (CMS) issued 
regulations with new IDTF performance standards.  
This study relies on Medicare Part B claims and enrollment  data from 
1995 to 2005. 
FINDINGS 
From 1995 to 2005, advanced imaging paid under the Medicare 
Physician Fee Schedule grew more than fourfold, from 1.4 million to 
6.2 million services.  By 2005, advanced imaging billed under the MPFS  
made up nearly one-quarter of all advanced imaging covered by Medicare.  
Allowed charges and utilization rate per beneficiary grew by a similar 
magnitude, to $3.5 billion and 163 services per 1,000 beneficiaries.   
  OEI-01-06-00260   GROWTH IN  ADVANCED IMAGING  PAID  UNDER THE  MEDICARE PHYSICIAN FEE  SCHEDULE   i  EE  XX EE CC UU TT II VV EE    SS UU MM MM AA RR YY
    
 
Services provided by IDTFs accounted for nearly 30 percent of 
the total growth in advanced imaging under the MPFS.   Between 
1995 and 2005, the percentage of advanced imaging services paid 
under the MPFS that were provided by Independent Physiological 
Labs (IPL) and IDTFs grew from 2.6 to 23 percent. This represents a 
growth of nearly 1.4 million services, or 29 percent of the growth in 
advanced imaging from 1995 to 2005.  
Growth varied widely  among States, from 24 percent to over 
1,000 percent. Between 1995 and 2005, the number of advanced 
imaging services billed per 1,000 beneficiaries grew in every State, with 
the median States utilization rate increasing from 29 to 126 services per 
1,000 beneficiaries. States that began the period with the lowest rates 
experienced  the most growth. Levels of use in many of the high-growth 
States, however, still do not approach those of States in which advanced  
imaging is most frequently performed. 
In every  year from 1995 to 2005, a  small number of procedure codes  
consistently accounted for over half of all advanced imaging billed 
under the MPFS.  In each year, the 10 most frequently billed  procedure 
codes accounted for close to 60 percent of all advanced imaging services 
billed under the MPFS. Top codes remained largely unchanged: four of  
the top five codes were the same in 1995 and in 2005. 
RECOMMENDATION 
The growth in advanced imaging paid under the  MPFS raises questions 
and challenges for the Medicare program, particularly regarding the 
quality and appropriateness of services. Ongoing OIG work is focusing 
on different aspects of this growth, including a more specific 
examination of how advanced imaging services are provided in  
ambulatory settings. In light of the growth we describe in this report, 
we recommend that: 
CMS Monitor the Growth of  Advanced Imaging Performed in  
Ambulatory Settings 
CMS should conduct such monitoring as part of its efforts to  ensure that 
Medicare beneficiaries receive reasonable, appropriate, and high-quality  
imaging services in ambulatory settings. The rapid growth of IDTFs in 
providing advanced imaging reinforces the importance of implementing 
our prior recommendation that CMS consider conducting site visits to 
monitor IDTFs compliance with Medicare requirements. 
OEI-01-06-00260   GROWTH IN  ADVANCED IMAGING  PAID  UNDER THE  MEDICARE PHYSICIAN FEE  SCHEDULE   ii  E X E C U T I V E   S U M M A R Y
   
 
AGENCY COMMENTS 
CMS concurred with our recommendation and shares OIGs concern 
about the growth of imaging services.  CMS described steps it took in 
July 2007 to improve oversight of IDTFs. CMS commented that IDTFs 
receive site  visits when newly enrolled and when reportable changes in 
their operations occur.  However,  it  stated that it lacks funding to 
support unannounced site visits of IDTFs. 
 
  OEI-01-06-00260   GROWTH IN  ADVANCED IMAGING  PAID  UNDER THE  MEDICARE PHYSICIAN FEE  SCHEDULE   iii   
  T A B L E   O F   C O N T E N T S  
EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i
  
 
 
I N T RO DUC T IO N  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1 
  
 
 
F I N D IN G S  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  6 
  
  Advanced imaging grew more than fourfold  . . . . . . . . . . . . . . . . . .  6 
  
  Services provided by IDTFs grew the most . . . . . . . . . . . . . .  . . .. .8
   
  Growth varied widely among States  . . . . . . . . . . . . . . . . . . . . . . .  10 
  
  A few procedure codes accounted for over half of all services . . . .  13 
  
 
 
R E C O MMEN D A T ION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  14 
  
 
 
APPENDIXES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  16 
  
  A:  Methodology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  16 
  
  B:  Data Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  19 
  
  C:  Agency Comments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  30 
  
 
 
A C K NO WL E D G M E N T S  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  33 
   I N T R O D U C T I O N  
  I N T R O D U C T I O N  
OBJECTIVE 
To determine the extent and nature of growth in advanced imaging 
paid under the Medicare Physician Fee Schedule from 1995 to 2005. 
BACKGROUND 
Advanced imaging used to be the exclusive domain of hospitals; 
however, in the last 10 to 15 years, the Medicare program has seen  
the use of these services proliferate in ambulatory settings.  This 
study documents the extent and nature of this growth by analyzing 
services paid under the  Medicare Physician Fee Schedule (MPFS), one 
of Medicares main payment systems for ambulatory care.  Ongoing 
Office of Inspector General (OIG) work will focus on how advanced 
imaging services are furnished in ambulatory settings. 
Overview of Advanced Imaging 
Advanced imaging, such as magnetic resonance (MR), computed 
tomography (CT), and positron emission tomography (PET), enables 
doctors to diagnose and treat patients by providing detailed images of  
tissues deep inside the body.  Advances in technology are dramatically 
expanding the number of clinical applications for advanced imaging.  
MR, CT, and PET scans are used to detect and treat a growing 
number of conditions, including cancer, heart disease, damage to 
bones and organs, and brain disorders such as Alzheimers disease 
and Parkinsons disease.  Technological progress has also facilitated 
the provision of advanced imaging services in ambulatory settings, 
which has the potential to increase convenience and improve health 
outcomes for Medicare beneficiaries.   
Components of Advanced Imaging 
Medicare divides imaging services into two components:  the technical 
component,  which is taking an image of the patient, and the  
professional component, which is a doctors interpretation of the 
image.  Medicare may pay for the components separately if each was 
performed by a different provider, or it may make a global payment to  
one provider as payment for both components.   Separate payments 
are common for services performed in hospitals.  For such services,  
Medicare covers the technical component in its facility payment to the 
hospital and makes a separate payment to a doctor for the 
professional component.   
 
  OEI-01-06-00260   GROWTH IN  ADVANCED IMAGING  PAID  UNDER THE  MEDICARE PHYSICIAN FEE  SCHEDULE   1  I N T R O D U C T I O N
   
Payment for Advanced Imaging in Ambulatory Settings 
The main Medicare payment systems for advanced imaging in 
ambulatory settings are the MPFS and the Hospital Outpatient 
Prospective Payment System (OPPS).1 The MPFS, effective in 1992, 
establishes payment rates for services furnished by providers such as 
doctors, group practices, independent diagnostic testing facilities 
(IDTFs), and certain other medical professionals.2  Of note, the MPFS  
covers the professional component of imaging, even for scans 
performed in hospitals and hospital outpatient departments.  The  
OPPS, effective in 2000, covers the technical component of imaging 
provided during visits to hospital outpatient departments. 
Oversight of Ambulatory  Settings That Provide Advanced Imaging 
Oversight of ambulatory settings that provide advanced imaging in 
the Medicare program varies.  Hospital outpatient departments must 
be part of a hospital that is enrolled in Medicare and maintains either 
accreditation by an approved accreditor or certification by a State 
survey agency.3  To earn  accreditation or  certification, hospitals must 
demonstrate that they meet a set of minimum quality and safety 
standards and undergo inspections to monitor their compliance.4   
Doctors and group practices must maintain relevant professional 
licensure in the State where they operate.5  IDTFs undergo an initial 
onsite inspection by a Medicare carrier when they enroll in the 
Medicare program and must remain compliant with standards 
covering, among other things, the proficiency of  employees, the 
ordering of tests, and State licensure.6    
Independent Diagnostic Testing Facilities 
According to the Centers for Medicare & Medicaid Services (CMS), an 
IDTF is a fixed location, a mobile entity, or an individual 
nonphysician practitioner that performs diagnostic procedures.7   
IDTFs may provide many different types of services; however,  
diagnostic imaging represents the majority of their Medicare 
 
1 Social Security Act  1833(t). 

2 Social Security Act  1848. 

3 Social Security Act  1861(e); Social Security Act  1865. 

4 42 CFR  482. 

5 Social Security Act  1861(r). 

6 42 CFR  410.33; CMS, Medicare Program Integrity Manual, Chapter 10:  Healthcare 

Provider/Supplier Enrollment (4196), Rev. 150, June 6, 2006. 

7 42 CFR  410.33. 

  OEI-01-06-00260   GROWTH IN  ADVANCED IMAGING  PAID  UNDER THE  MEDICARE PHYSICIAN FEE  SCHEDULE   2  I N T R O D U C T I O N
   
reimbursement.8  A freestanding imaging center in a medical office 
park or shopping mall is one example of an IDTF.    
The predecessors to IDTFs are independent physiological laboratories 
(IPLs). In 1998, OIG issued two reports outlining problems and 
vulnerabilities with IPLs, including providers out of compliance with 
Medicare requirements and potential fraud and abuse.9  10  In 1999, 
IDTFs effectively replaced IPLs; however, similar problems persist.   
A 2006 OIG review of IDTFs found substantial noncompliance with 
Medicare enrollment standards.  That review also found claims that 
did not meet Medicare billing requirements, leading to estimated 
improper payments of $71.5 million.11  The report recommended that 
CMS recover overpayments and consider performing site visits to 
monitor compliance with IDTFs initial enrollment applications and 
subsequent updates. 
In December 2006, CMS issued final regulations that established 
IDTF performance standards covering, among other things, liability 
insurance, disclosure of  ownership interests, and access to IDTFs and 
their records through unannounced onsite inspections by CMS.12 In 
the preamble to those regulations, CMS cited OIGs report and other  
concerns with IDTFs as the rationale for establishing performance 
standards. CMSs other concerns included fraud, which it had 
identified in several States, and the over 400-percent growth in the 
number of IDTFs in California billing Medicare between 2000 and 
2005. 
 
8 MedPAC, A Data Book:  Healthcare Spending  and the Medicare Program, June 2004,  
p. 135. 
9 OIG, Independent Physiological Laboratories:  Vulnerabilities Confronting Medicare, 

OEI-05-97-00240, August 1998. 
 
10 OIG, Independent Physiological Laboratories:  Carrier Perspectives, OEI-05-97-00241, 

August 1998. 

11 OIG, Review of Claims Billed by Independent Diagnostic Testing Facilities for Services 

Provided to Medicare Beneficiaries During Calendar Year 2001, OAS-03-03-00002, June 

2006. 

12 71 FR 69,624, 69,695 (December 1, 2006) (to be codified at 42 CFR  410). 

  OEI-01-06-00260   GROWTH IN  ADVANCED IMAGING  PAID  UNDER THE  MEDICARE PHYSICIAN FEE  SCHEDULE   3  III NNN TTT RRR OOO DDD UUU CCC TTT III OOO NNN
     
 
METHODOLOGY 
This study relies primarily on analysis of Medicare claims and 
enrollment data. 
Scope 
This study focuses on advanced imaging services paid under the 
MPFS from 1995 to 2005. In this study, we define advanced imaging 
as CT, MR, and PET. 
Analysis 
We analyzed annual summary files  of MPFS claims data from CMSs 
Part B Extract and Summary System (BESS). For each year, we used 
Healthcare  Common Procedure Coding System (HCPCS) procedure  
codes to identify BESS records representing CT, MR, and PET 
services. Once we identified records for advanced imaging, we used 
the procedure modifier codes contained on the records to categorize 
them as those for the technical component, the professional  
component,  or a global service.   
We calculated allowed services and charges at the HCPCS level and 
then summed these to create annual totals. Our count of services 
paid under the MPFS is the sum of technical components and global 
services. Our count of all advanced imaging services paid by 
Medicare is the sum of those paid under the MPFS and those paid  
outside of the MPFS. To calculate total allowed charges, we added 
allowed charges for global services, technical component services, and 
professional component  services associated with technical component 
claims. 
We used annual enrollment files published on CMSs Web site to 
calculate utilization rates per 1,000 Medicare beneficiaries. We 
subtracted beneficiaries  in managed care plans from our counts 
because services for these beneficiaries are not contained in the BESS 
summary records that we used to  count services.   
To determine the types of providers that billed for advanced imaging, 
we used the provider specialty code  on the BESS summary records.  
Of note, CMS considers  an IDTF to be a provider specialty rather 
than a place of service. 
Please see Appendix A for a full discussion of our  methodology. 
OEI-01-06-00260   GROWTH IN  ADVANCED IMAGING  PAID  UNDER THE  MEDICARE PHYSICIAN FEE  SCHEDULE   4  I N T R O D U C T I O N
   
Standards 
We conducted this study in accordance with the Quality Standards for 
Inspections issued by the Presidents Council on Integrity and 
Efficiency and the Executive Council on Integrity and Efficiency. 
  OEI-01-06-00260   GROWTH IN  ADVANCED IMAGING  PAID  UNDER THE  MEDICARE PHYSICIAN FEE  SCHEDULE   5    F I N D I N G S  
From 1995 to 2005, advanced imaging paid  By 2005, advanced imaging paid 
under the Medicare Physician Fee Schedule  under the MPFS made up nearly 
one-quarter  of all advanced  
grew  more than fourfold, from 1.4 million to  
imaging paid by Medicare, 
6.2 million services 
increasing from 15 percent in 1995 
to 23 percent in 2005. Over the 
same period, advanced imaging billed by hospitals and other providers 
paid outside of the MPFS grew by about 2.5 times.  On average, the  
number of allowed services paid under the MPFS grew by about  
16 percent per year from 1995 to 2005.  Growth was highest between 
2000 and 2001, when the number of services increased 26 percent.  
Chart 1 shows 10-year growth of MPFS advanced imaging by total 
allowed services and total allowed charges.  (See Tables 1 and 2 in 
Appendix B for annual growth in services and charges for each imaging 
modality.) 
 
Chart 1:   Growth in Allowed Services and Allowed Charges for
  
 
Advanced Imaging Paid Under the MPFS, 1995 to 2005
 
 
7.0  $7 
6.2 
 
6.0  $6 
5.4 
s)    s) 
n n
o 5.0  4.5  $5 o
 ervices (in milli 43..00       2.5  3.1  3.8  $3.46  $$43 harges (in $billi
d s 1.8  2.1  $2.94  d c
we 2.0  1.4  1 .5  1.6  $2.35  $2 we
o o
All   $1.87  All
$1.62 
1.0  $1
$1.21 
  $0.84  $0.97 
$0.62  $0.66  $0.70 
0.0  $0 
1995  19 96  1997  1998  1999  2000  2001  2002  2003  2004  2005 
  Allowed services  Allowed charges 
Source:  OIG analysis of  Part B data, 2007. 
From 1995 to 2005, the number of CT services grew fourfold, from just 
over 800,000 to 3.2 million services.  Over this period, the percentage of 
all Medicare CT services paid under the MPFS grew from 11 to  
16 percent.  
  OEI-01-06-00260   GROWTH IN  ADVANCED IMAGING  PAID  UNDER THE  MEDICARE PHYSICIAN FEE  SCHEDULE   6  FF II NN DD II NN GG SS  

The number of MR services also grew fourfold over this period, from  
about 630,000 to 2.7 million services. By 2005, 43 percent of all 
Medicare-covered MR services were  paid under the MPFS, up from 
36 percent in 1995. 
PET was first covered by Medicare in 1996. As coverage of the 
technology expanded, it became the fastest growing of the three 
modalities, to about 228,000 services in 2005. Between 1996 and 2005, 
the share of all PET services that was paid under the MPFS increased  
from 26 to 59 percent. 
From 1995 to 2005, allowed charges grew more than fivefold, to $3.5 billion 
Because PET and MR are costlier than CT, their growth caused allowed 
charges to increase at a faster rate than allowed services.13 For 
example, although PET imaging accounts for only about 5 percent of the 
growth in services, it accounts for more than 18 percent of the growth in  
allowed charges. Similarly, MR accounts for about 45 percent of the 
growth in services, but 53 percent of the growth in allowed charges. See  
Chart 1 for growth in allowed charges overall.  See Charts 2a and 2b to 
compare each modalitys share of total growth in services with its share 
of total growth in charges. 
Chart  2a: Percentage of  Total Growth in Allowed 
 Chart 2b: Percentage of  Total Growth in Allowed  
Services by  Imaging Modality, 1995 to  2005
  Charges by Imaging Modality, 1995 to 2005 
4.8% 
18.3% 
44.5%  MR  MR 
CT  CT 
53.0% 
PET  PET 
50.7% 
28.7% 
Source: OIG analysis of Part B data, 2 0 07. 
The utilization rate of advanced imaging grew  from 42 services per 
1,000 beneficiaries in 1995 to 163 in 2005 
After trailing the annual growth in MR utilization rates from 1996 to 
2001, annual growth of CT outpaced that of MR from 2002 to 2005. As 
of 2005, CT remained the most frequently used of the three modalities, 
 
13 Average allowed charges per service in 2005 for CT, MR, and PET were $351, $726, and 
$2,305, respectively. 
OEI-01-06-00260   GROWTH IN  ADVANCED IMAGING  PAID  UNDER THE  MEDICARE PHYSICIAN FEE  SCHEDULE   7  F I N D I N G S  

with 85 services performed for every 1,000 beneficiaries.  Chart 3 shows 
growth in utilization rates for each type of imaging and for the three 
modalities combined. 
Chart  3:  Growth in Advanced Imaging Utilization Rates,  1995 to 2005 
175 
163 
150 
s
e
ari 125 
ci
efi All modalities 
n
Be 100  CT 
0  85 
0 MR 
0
r 1, 75  PET 
pe 72 
s 
e
c 50 
vi
er 42 
S
24 
25 
18 
6 
0  0 
1995  1996  1997  1998  1999  2000  2001  2002  2003  2004  2005 
Source:  OIG analysis of Part B data, 2007. 
 
 
Services provided by  IDTFs accounted for      Between 1995 and 2005, the 
nearly 30 percent of the total growth in  percentage of all advanced 
imaging services paid under the 
advanced imaging under the MPFS 
MPFS that were provided by IPLs 
and IDTFs grew from 2.6 to 23 percent.  This represents a growth of 
nearly 1.4 million services.  IDTFs accounted for almost 40 percent of 
growth in MR and PET but only 20 percent of growth in CT.  Although 
the share of all services  paid under the provider  specialty category of 
diagnostic radiology decreased between 1995 and 2005, the specialty 
saw growth of more than 2.3 million services overall.  See Tables 1 and 
2 to compare the top five provider specialties in 1995 and 2005.  (See 
Tables 3 through 6 of Appendix B for counts of services by provider 
specialty overall and for each type of imaging.)   
 
  OEI-01-06-00260   GROWTH IN  ADVANCED IMAGING  PAID  UNDER THE  MEDICARE PHYSICIAN FEE  SCHEDULE   8  FFF III NNN DDD III NNN GGG SSS  

 
  Table 1: Concentration of MPFS  Advanced Imaging  Services by  
Five  Most Common Specialties, 1995 
 
Number of   Percentage of  
 
Specialty  services  total services 
  Diagnostic radiology  1,203,662  83% 
  Neurology  39,203  3% 
  IDTF*  37,939  3% 
  Multispecialty clinic/group  33,992  2% 
  Interventional radiology  28,991  2%
   Total Top Five  1,343,787  93% 
* In 1995, IDTFs were classified  as IPLs. 
 
Table 2: Concentration of MPFS  Advanced Imaging  Services by  
 
Five  Most Common Specialties, 2005 
 
Number of   Percentage of  
  Specialty  services  total services 
    Diagnostic radiology  3,556,470  58% 
  IDTF  1,403,156  23% 
  Orthopedic surgery  160,672  3% 
  Internal medicine  132,097  2% 
  Hematology/oncology  120,256  2%
   Total Top Five  5,372,651  88% 
Source: OIG analysis of Part B data, 2007. 
 
Chart 4 shows that while IDTFs account for a much larger share of total 
services in 2005 than in 1995, diagnostic radiology is still the specialty 
under which most advanced imaging is billed and accounted for half of  
the growth between 1995 and 2005. 
 
OEI-01-06-00260   GROWTH IN  ADVANCED IMAGING  PAID  UNDER THE  MEDICARE PHYSICIAN FEE  SCHEDULE   9  FFF III NNN DDD III NNN GGG SSS  

 
Cha rt 4: Advanced Imaging Services by Provider Specialty, 1995 and 2005 
 
6,000,000 
 
 
5,000,000   
 
All other 
 
r  4,000,000  specialties 
a
e
r y   IDTF 
e
p
s   
ce 3,000,000  Diagnostic 
rvi   radiology 
e
S
 
2,000,000 
 
 
1,000,000 
 
 
0   
1995*  2005 
 
* In 1995, IDTFs were classified  as IPLs. 
 
 
Source: OIG analysis of Part B data, 2007. 
 
Growth varied widely  among States, 
Between 1995 and 2005, the 
from 24 percent to over 1,000 percent 
number of MPFS advanced 
imaging services paid per 1,000 beneficiaries grew in every State and in 
one State more than tenfold. Typical growth was about 336 percent 
over the 10-year period, with the median States utilization rate 
increasing from 29 to 126 services per 1,000 beneficiaries.   
States that began the period with the lowest rates experienced the most 
growth. Levels of use in many of the high-growth States, however, still 
do not approach those of States in which advanced imaging is most  
frequently performed. For example, many Rocky Mountain States 
experienced high growth in the rate of services per beneficiary, but they  
still remain fairly low users of imaging relative to some southern and 
OEI-01-06-00260   GROWTH IN  ADVANCED IMAGING  PAID  UNDER THE  MEDICARE PHYSICIAN FEE  SCHEDULE   10  F I N D I N G S  

northeastern States. See Figure 1 for growth in advanced imaging 
services per 1,000 beneficiaries and Figure 2 for utilization rates in 
2005. 
 
 
 
 
 
 
 
 
 
 
 
 
  OEI-01-06-00260   GROWTH IN  ADVANCED IMAGING  PAID  UNDER THE  MEDICARE PHYSICIAN FEE  SCHEDULE   11   F I N D I N G S  

 
 
 
Wide variation remains in utilization rates across States 
In 2005, the State with the lowest utilization rate, Vermont, had  
8 advanced imaging services paid under the MPFS for every   
1,000 beneficiaries.  The State with the highest utilization rate in 2005, 
Florida, had 326 services for every 1,000 beneficiaries.  (See Table 7 in 
Appendix B for growth in utilization rates by State.) 
  OEI-01-06-00260   GROWTH IN  ADVANCED IMAGING  PAID  UNDER THE  MEDICARE PHYSICIAN FEE  SCHEDULE   12  FF II NN DD II NN GG SS  

In every  year from 1995 to 2005,    In 1995, the MPFS covered 
a small number of procedure codes consistently   77 different advanced imaging 
procedure codes. By 2005, this 
accounted for over half of all advanced imaging 
number had grown to 170, with 
billed under the MPFS 
the greatest growth occuring in 
2001, when 53 new procedure 
codes were included. Yet the bulk of billing volume remained 
concentrated among a relatively small number of procedure codes. In  
each of the 11 years from 1995 to 2005, the 10 most frequently billed 
procedure codes accounted for about  60 percent of all advanced imaging 
paid under the MPFS. Also, the most common procedure codes 
remained largely unchanged. The combined list of top 10 codes for 
every year between 1995 and 2005 comprises only 13 different codes, 
and 4 of the top 5 procedure codes were the same in 1995 and in 2005. 
See Table 3 for a list of the top 10 codes in 2005 and the number of 
years each was in the top 10. 
Table 3: Ten Most Frequently  Billed Advanced Imaging  Procedure Codes, 2005 
Number of  
years in  the 
Number of   Percentage of   top 10 from  
Procedure code  Procedure description*  services  total services  1995 to 2005 
72148  MRI lumbar spine w/o dye  557,646  9%  11 
72193  CT pelvis w/dye  421,056  7%  11 
71260  CT thorax w/dye  392,140  6%  11 
70553  MRI brain w/o & w/dye  366,977  6%  11 
74160  CT abdomen w/dye  351,257  6%  11 
73721  MRI joint of lower extremity w/o dye  336,795  5%  10 
74170  CT abdomen w/o & w/dye  307,854  5%  11 
71250  CT thorax w/o dye  265,931  4%  4 
73221  MRI joint upper extremity w/o dye  239,545  4%  2 
72141  MRI neck spine w/o dye  225,293  4%  11
 Total  3,464,494  56% 
* Procedure descriptions are copyrighted by the American Medical Association. 

Source: OIG analysis of Part B data, 2007. 

OEI-01-06-00260   GROWTH IN  ADVANCED IMAGING  PAID  UNDER THE  MEDICARE PHYSICIAN FEE  SCHEDULE   13    CR OE CN OC ML UM SE INOD NA   T I O N  
 
The growth of advanced imaging in ambulatory settingsthose for 
which Medicare payment is made under the MPFSis a trend that is 
likely to continue as new technology and clinical applications become 
available. Although this growth has the potential to increase 
convenience and improve health outcomes for beneficiaries, it also 
raises questions and challenges for the Medicare program.   For 
example, the wide range of growth and utilization rates across States 
raises questions about what drives variability in the use of advanced 
imaging. Growth of advanced imaging in ambulatory settings poses a 
challenge for quality oversight of the Medicare program.  Rapid growth 
also raises concerns about inappropriate use of services, which can be 
costly for both Medicare and its beneficiaries.  Ongoing OIG work is 
focusing on different aspects of this  growth, including a more specific 
examination of how advanced imaging services are provided in  
ambulatory settings.   
IDTFs are increasingly prominent providers of advanced imaging 
services.  In 2005, they provided 1.4 million services, or 23 percent of all 
advanced imaging paid under the MPFS.  In 2006, an OIG review found 
numerous problems with IDTFs, including noncompliance with 
Medicare requirements and services that were not reasonable and 
necessary.14   At that time, OIG recommended that CMS consider 
performing  site visits to monitor compliance with IDTFs enrollment 
applications and subsequent updates.  In response to OIGs review, 
CMS issued final regulations that established IDTF performance 
standards.15   In January 2007, CMS issued a transmittal giving 
technical direction to Medicare carriers regarding oversight of the new 
performance standards.  CMS rescinded this transmittal in February 
2007.16  
In our draft report, we recommended that CMS monitor the growth of 
advanced imaging performed in ambulatory settings.  As part of such  
monitoring, we stated that CMS should reissue technical direction to 
 
14 Department of Health and Human Services, OIG, Review of Claims Billed by  
Independent Diagnostic Testing Facilities for Services Provided  to Medicare Beneficiaries 
During Calendar Year 2001, OAS-03-03-00002, June 2006. 
15 71 FR 69,624, 69,695 (December 1, 2006) (to be codified at 42 CFR part 410). 
16 CMS, Transmittal 187, January 26, 2007. 
  OEI-01-06-00260   GROWTH IN  ADVANCED IMAGING  PAID  UNDER THE  MEDICARE PHYSICIAN FEE  SCHEDULE   14   R E C O M M E N D A T I O N   
Medicare carriers regarding oversight of the new IDTF performance 
standards. 
Subsequent to OIGs issuance of the draft report, CMS issued new 
technical direction to the Medicare carriers regarding the IDTF 
performance standards on July 13, 2007.17  It also published a proposed  
rule in the Federal Register on July 12, 2007, that if adopted would 
revise and clarify the IDTF performance standards.  Although these 
actions partially address our recommendation, we continue to  
recommend that: 
CMS Monitor the Growth of  Advanced Imaging Performed in  
Ambulatory Settings 
CMS should conduct such monitoring as part of its efforts to  ensure that 
Medicare beneficiaries receive reasonable, appropriate, and high-quality  
imaging services in all ambulatory settings, including IDTFs.  Further, 
the rapid growth of IDTFs in providing advanced imaging reinforces the 
importance  of implementing our prior recommendation that CMS 
consider conducting site visits to monitor IDTFs compliance with 
Medicare requirements.  
 
AGENCY COMMENTS 
CMS concurred with our recommendation and shares OIGs concern 
about the growth in advanced imaging. CMS described steps it took in 
July 2007 to improve oversight of IDTFs, including issuing new 
technical direction regarding the IDTF performance standards and a 
proposed rule to revise and clarify the standards.  CMS commented that  
it requires contractors to conduct site visits of IDTFs when newly 
enrolled and when reportable changes in their operations occur.   
However, it stated that it lacks funding to support unannounced site 
visits to IDTFs. The full text of CMSs comments is provided in 
Appendix C.  
 
17 CMS, Transmittal 216, July 13, 2007. 
  OEI-01-06-00260   GROWTH IN  ADVANCED IMAGING  PAID  UNDER THE  MEDICARE PHYSICIAN FEE  SCHEDULE   15  R E C O M M E N D A T I O N  
  A P P E N D I X ~ A
 
METHODOLOGY 
This study relies primarily on analysis of Medicare claims and 
enrollment data. 
Scope 
This study focuses on advanced imaging services paid under the 
Medicare Physician Fee Schedule (MPFS) from 1995 to 2005 for the 
50 States, the District of Columbia, and Puerto Rico.  In this study, 
we define advanced imaging as computed tomography, magnetic 
resonance, and positron emission  tomography.  We identify imaging 
services using the technical portion of the service.  Thus, we count a 
service as paid under the MPFS if its technical component was paid 
under the MPFS, either  as a claim for the technical component only or 
as a claim for the global service.  When only the  professional  
component of an imaging service was paid under the MPFS, we  
consider it covered outside of the MPFS.  
Analysis 
We analyzed annual summary files  of MPFS claims data from the 
Centers for Medicare &  Medicaid Services (CMS) Part B Extract and 
Summary System (BESS).  For each  year, these files contain counts of 
allowed services and charges by Healthcare Common Procedure 
Coding System (HCPCS) procedure  code, with detailed totals by 
procedure modifier code, Medicare carrier number, provider specialty 
code, and other variables. 
To identify records for advanced imaging services in each annual file, 
we compiled a list of HCPCS codes specific to that year.  We developed 
these lists by examining narrative descriptions of the procedure codes  
in CMSs annual HCPCS file, analyzing Medicare coverage policy, and 
reviewing printed coding manuals published by CMS and the  
American Medical Association.  
Once we identified records for advanced imaging, we used the 
procedure modifier codes to determine whether the record referred to  
the technical component, the professional component, or a global 
service.  We  identified technical component records by checking the 
first and second modifier variables for the value of TC.  We 
identified professional component records by checking for a value of 
26. We identified global services by checking for either no  modifiers 
or for any value other than TC or 26.  After categorizing the 
  OEI-01-06-00260   GROWTH IN  ADVANCED IMAGING  PAID  UNDER THE  MEDICARE PHYSICIAN FEE  SCHEDULE   16  A P P E N D I X ~ A  

records, we  summed allowed services by State, HCPCS code, 
component of service, and provider specialty code. 
To calculate the percentage of advanced imaging services paid under 
the MPFS,  we needed to determine the number of advanced imaging 
services reimbursed under some payment system other than the 
MPFS. Since the professional component of imaging is paid under the  
MPFS, we used professional component services  paid under the MPFS  
that did not have corresponding technical component services as a 
proxy for services provided outside of the MPFS.  Thus, for each 
HCPCS code, we subtracted the total count of services billed as the 
technical component from the total count of services billed as the 
professional component.  The remaining professional component 
services represent the count of services paid under some system other 
than the MPFS for that HCPCS code. 
To calculate total allowed charges, we summed allowed charges by 
HCPCS code.  Allowed charges for each HCPCS code include those for  
global services, technical component  services, and professional 
component services associated  with MPFS technical component 
claims. First, we summed allowed services and charges for technical 
component claims.  Next, we calculated average allowed charges per  
professional component  service for each HCPCS code.  We then 
multiplied the count of technical component services by the average 
allowed charge for the professional component to arrive at allowed 
charges for the professional component services.  Finally, we summed 
technical, professional, and global charges to calculate total charges 
for each HCPCS code.  To reflect geographic variation in 
reimbursement amounts, we calculated charges by HCPCS code at 
the carrier pricing locality level.    
We used annual enrollment files published on CMSs Web site by its 
Center for Beneficiary Choices to  calculate utilization rates per  
1,000 Medicare beneficiaries.  Each annual file contains county-level 
counts of beneficiaries with Part A or Part B coverage and of those 
enrolled in managed care plans. For our analysis, we summarized 
these files to the State level.  We subtracted beneficiaries in managed  
care plans from our counts because services for these beneficiaries are 
not contained in the BESS summary records that we used to count 
services. 
To determine the types of providers that billed for advanced imaging, 
we used the provider specialty code  on the BESS summary records.  
  OEI-01-06-00260   GROWTH IN  ADVANCED IMAGING  PAID  UNDER THE  MEDICARE PHYSICIAN FEE  SCHEDULE   17  AA PP PP EE NN DD II XX ~~ AA  

Of note, because CMS identifies IDTFs as a provider specialty, we 
used the provider specialty code to identify services provided  by 
IDTFs. 
We used SAS software to conduct our analysis. 
Limitations 
This study relies on data produced by CMS; we did not attempt to 
independently verify these data. 
Our analysis is limited by the way CMS collects and maintains the data 
we used for this study. Because of a limitation in the enrollment data 
we used, we were unable to include Railroad Retirement Board  
beneficiaries in our State-level counts of beneficiary populations. There  
were about 600,000 of these beneficiaries in 2005. Also, the annual 
enrollment figures we used overstate the population by 2 to 3.5 percent 
because they include all beneficiaries who had Part A or B coverage at 
any point during the year. 
We base our calculations of the percentage of services paid under the  
MPFS and of allowed charges on the assumption that each technical 
component service has one professional component service.   Our tests 
against the 100-percent Part B National Claims History file for 2004 
show that, while this assumption is largely true, it is not entirely so.  
Therefore, we acknowledge that using the data in this way could cause 
us to slightly overstate these calculations. 
 
OEI-01-06-00260   GROWTH IN  ADVANCED IMAGING  PAID  UNDER THE  MEDICARE PHYSICIAN FEE  SCHEDULE   18    A P P E N D I X ~ B
Table 1:  Growth in Allowed Services for  Advanced Imaging Under the MPFS, by Year,  1995 to 2005 
Three modalities combined  CT  MR  PET 
Percentage   Percentage   Percentage   Percentage 
change from   change from   change from   change from  
Year  Allowed services  previous year  Allowed  services  previous year  Allowed services  previous year  Allowed  services  previous year 
1995  1,443,496  813,533  629,963  n/a  n/a 
1996  1,547,568  7.2%  854,894  5.1%  692,007  9.8%  667  n/a 
1997  1,649,677  6.6%  878,929  2.8%  769,989  11.3%  759  13.8% 
1998  1,841,568  11.6%  974,631  10.9%  865,512  12.4%  1,425  87.7% 
1999  2,073,473  12.6%  1,081,697  11.0%  987,827  14.1%  3,949  177.1% 
2000  2,489,501  20.1%  1,281,810  18.5%  1,197,107  21.2%  10,584  168.0% 
2001  3,143,334  26.3%  1,575,105  22.9%  1,521,171  27.1%  47,058  344.6% 
2002  3,845,067  22.3%  1,944,322  23.4%  1,830,805  20.4%  69,940  48.6% 
2003  4,526,251  17.7%  2,296,345  18.1%  2,115,620  15.6%  114,286  63.4% 
2004  5,385,696  19.0%  2,742,063  19.4%  2,476,251  17.0%  167,382  46.5% 
2005  6,161,162  14.4%  3,203,399  16.8%  2,729,321  10.2%  228,442  36.5% 
Table 2:  Growth in Allowed Charges for  Advanced Imaging Under the MPFS, by Year,  1995 to 2005 
Three modalities combined  CT  MR  PET 
Percentage   Percentage   Percentage   Percentage 
change from   change from   change from   change from  
Year  Allowed charges  previous year  Allowed charges  previous year  Allowed  charges  previous year  Allowed charges  previous year 
1995  $617,211,512  n/a  $232,573,625  n/a  $384,637,887  n/a  n/a  n/a 
1996  $661,031,293  7.1%  $240,126,894  3.2%  $419,980,806  9.2%  $923,593  n/a 
1997  $699,923,303  5.9%  $242,616,653  1.0%  $456,200,175  8.6%  $1,106,475  19.8% 
1998  $841,894,277  20.3%  $286,436,669  18.1%  $552,934,338  21.2%  $2,523,270  128.0% 
1999  $966,552,545  14.8%  $323,285,552  12.9%  $635,363,604  14.9%  $7,903,390  213.2% 
2000  $1,210,063,498  25.2%  $398,272,190  23.2%  $789,565,479  24.3%  $22,225,829  181.2% 
2001  $1,624,150,492  34.2%  $505,870,196  27.0%  $1,047,661,561  32.7%  $70,618,735  217.7% 
2002  $1,866,251,391  14.9%  $567,527,989  12.2%  $1,150,387,917  9.8%  $148,335,485  110.1% 
2003  $2,348,112,112  25.8%  $705,542,485  24.3%  $1,393,543,032  21.1%  $249,026,596  67.9% 
2004  $2,944,462,862  25.4%  $882,192,069  25.0%  $1,694,607,425  21.6%  $367,663,368  47.6% 
2005  $3,461,225,352  17.6%  $1,047,959,778  18.8%  $1,893,326,580  11.7%  $519,938,995  41.4% 
Note: In all tables in this appendix, MPFS refers to the Medicare Physician Fee Schedule, CT to  computed tomography, MR to 
magnetic resonance, and PET to positron emission tomography.  
  OEI-01-06-00260   GROWTH IN  ADVANCED IMAGING  PAID  UNDER THE  MEDICARE PHYSICIAN FEE  SCHEDULE   19  A P P E N D I X ~ B  

Table 3:  Number and Percentage of Advanced Imaging Services  Billed Under the MPFS, by Provider Specialty, in  
1995 and 2005 
Number of advanced  Percentage of   Number of advanced   Percentage of  
Specialty   imaging services,   advanced imaging  imaging services,   advanced imaging 
Code  Specialty Description*  1995  services, 1995  2005  services, 2005 
00  Carrier wide  49  0.00%  0  0.00% 
01  General practice  7,125  0.49%  22,560  0.37% 
02  General surgery  3,153  0.22%  7,946  0.13% 
03  Allergy/immunology  130  0.01%  1,282  0.02% 
04  Otolaryngology  2,402  0.17%  24,487  0.40% 
05  Anesthesiology  565  0.04%  7,549  0.12% 
06  Cardiology  1,954  0.14%  57,086  0.93% 
07  Dermatology  45  0.00%  2,604  0.04% 
08  Family practice  6,642  0.46%  75,573  1.23% 
09  Gynecology  0  0.00%  1,540  0.02% 
10  Gastroenterology  2,583  0.18%  13,645  0.22% 
11  Internal medicine  16,599  1.15%  132,097  2.14% 
12  Osteopathic therapy  9  0.00%  515  0.01% 
13  Neurology  39,203  2.72%  74,805  1.21% 
14  Neurosurgery  4,127  0.29%  24,256  0.39% 
16  Obstetrics/gynecology  541  0.04%  2,547  0.04% 
18  Ophthalmology  195  0.01%  526  0.01% 
19  Oral surgery  41  0.00%  197  0.00% 
20  Orthopedic surgery  4,841  0.34%  160,672  2.61% 
22  Pathology  17  0.00%  240  0.00% 
24  Plastic surgery  86  0.01%  630  0.01% 
25  Physical medicine/rehab  198  0.01%  9,324  0.15% 
26  Psychiatry  42  0.00%  265  0.00% 
28  Colorectal surgery  33  0.00%  178  0.00% 
29  Pulmonary disease  2,281  0.16%  18,516  0.30% 
30  Diagnostic radiology  1,203,662  83.39%  3,556,470  57.72% 
31  Roentgenology, radiology**  0  0.00%  0  0.00% 
33  Thoracic surgery  1,398  0.10%  3,755  0.06% 
34  Urology  1,572  0.11%  79,498  1.29% 
36  Nuclear medicine  7,805  0.54%  32,285  0.52% 
37  Pediatric medicine  124  0.01%  710  0.01% 
38  Geriatric medicine  75  0.01%  479  0.01% 
39  Nephrology  346  0.02%  3,058  0.05% 
40  Hand surgery  2  0.00%  1,869  0.03% 
41  Optometry  0  0.00%  1  0.00% 
42  Cert nurse midwife**  0  0.00%  0  0.00% 
43  CRNA, anesth asst**  0  0.00%  0  0.00% 
44  Infectious disease  162  0.01%  2,071  0.03% 
45  Mammog screening  center  21  0.00%  0  0.00% 
46  Endocrinology  533  0.04%  2,778  0.05% 
47  IDTF  0  0.00%  1,403,150  22.77% 
* As listed  in the Centers for  Medicare & Medicaid Services (CMS) documentation. 

**  Specialty billed at least one advanced imaging service between 1995  and 2005, even  though counts in 1995  and 2005  were zero. 

  OEI-01-06-00260   GROWTH IN  ADVANCED IMAGING  PAID  UNDER THE  MEDICARE PHYSICIAN FEE  SCHEDULE   20  A P P E N D I X ~ B  

 
Table  3 (continued):  Number and  Percentage of Advanced  Imaging Services Billed Under the MPFS, by Provider  
Specialty, in 1995 and 2005 
Number of  advanced  Percentage of   Number of advanced  Percentage of  
Specialty   imaging services,   advanced imaging  imaging services,   advanced imaging 
Code  Specialty Description*  1995  services, 1995  2005  services, 2005 
48  Podiatry  127  0.01%  3,174  0.05% 
49  ASC  3  0.00%  6  0.00% 
50  Nurse practitioner  1  0.00%  2,903  0.05% 
51  Med supply w/orthotist  1,195  0.08%  0  0.00% 
54  Medical supply company  56  0.00%  0  0.00% 
58  Med supply w/pharmacist  1  0.00%  0  0.00% 
59  Ambulance service supplier**  0  0.00%  0  0.00% 
60  Public hlth/welfare agency  6  0.00%  2  0.00% 
63  Portable X-ray supplier  8,408  0.58%  4,446  0.07% 
65  Physical therapist  0  0.00%  4  0.00% 
66  Rheumatology  2,800  0.19%  27,669  0.45% 
68  Clinical psychologist**  0  0.00%  0  0.00% 
69  Clinical laboratory  2,578  0.18%  170  0.00% 
70  Multispec clinic/group  33,992  2.35%  3,836  0.06% 
71  Diagnostic X-ray**  0  0.00%  0  0.00% 
72  Diagnostic laboratory  0  0.00%  1,462  0.02% 
74  Occupational therapy  0  0.00%  7,712  0.13% 
75  Other medical  care**  0  0.00%  0  0.00% 
76  Peripheral vascular  disease  51  0.00%  90  0.00% 
77  Vascular surgery  219  0.02%  1,895  0.03% 
78  Cardiac surgery  43  0.00%  2,004  0.03% 
79  Addiction medicine**  0  0.00%  0  0.00% 
80  Licensed clin social worker**  0  0.00%  0  0.00% 
81  Critical care (intensivists)  32  0.00%  1,750  0.03% 
82  Hematology  130  0.01%  3,043  0.05% 
83  Hematology/oncology  8,196  0.57%  120,256  1.95% 
84  Preventive medicine  10  0.00%  204  0.00% 
85  Maxillofacial surgery  21  0.00%  36  0.00% 
86  Neuropsychiatry  49  0.00%  218  0.00% 
87  All other suppliers  15  0.00%  0  0.00% 
88  Unkn suppl/provider spclty  1,467  0.10%  4  0.00% 
89  Cert clin nurse specialist  0  0.00%  57  0.00% 
90  Medical oncology  2,590  0.18%  58,253  0.95% 
91  Surgical oncology  118  0.01%  1,130  0.02% 
92  Radiation oncology  4,870  0.34%  107,578  1.75% 
93  Emergency medicine  548  0.04%  6,700  0.11% 
94  Interventional radiology  28,991  2.01%  72,359  1.17% 
95  Indep physiological  lab  37,939  2.63%  6  0.00% 
97  Physician assistant  0  0.00%  3,775  0.06% 
98  Gynecologist/oncologist  388  0.03%  4,836  0.08% 
99  Unknown physician specialty  91  0.01%  420  0.01% 
   Total  1,443,496  100.00%  6,161,162  100.00% 
* As listed in CMS documentation. 

** Specialty billed at least  one advanced imaging service between 1995 and 2005, even though counts in 1995 and 2005 were zero. 

  OEI-01-06-00260   GROWTH IN  ADVANCED IMAGING  PAID  UNDER THE  MEDICARE PHYSICIAN FEE  SCHEDULE   21  A P P E N D I X ~ B  

Table 4:  Number and Percentage of CT Services Billed  Under the MPFS, by  Provider Specialty, in 1995 and 2005 
Specialty   Number of  CT  Percentage of CT   Number of CT   Percentage of CT  
Code  Specialty Description*  services, 1995  services, 1995  services, 2005  services, 2005 
00  Carrier wide  32  0.00%  0  0.00% 
01  General practice  4,826  0.59%  14,753  0.46% 
02  General surgery  2,676  0.33%  6,273  0.20% 
03  Allergy/immunology  84  0.01%  1,162  0.04% 
04  Otolaryngology  2,208  0.27%  23,657  0.74% 
05  Anesthesiology  306  0.04%  2,935  0.09% 
06  Cardiology  1,812  0.22%  45,489  1.42% 
07  Dermatology  43  0.01%  1,658  0.05% 
08  Family practice  5,953  0.73%  53,737  1.68% 
09  Gynecology  0  0.00%  783  0.02% 
10  Gastroenterology  2,572  0.32%  13,273  0.41% 
11  Internal medicine  14,922  1.83%  102,474  3.20% 
12  Osteopathic therapy  6  0.00%  33  0.00% 
13  Neurology  14,462  1.78%  9,248  0.29% 
14  Neurosurgery  2,290  0.28%  3,553  0.11% 
16  Obstetrics/gynecology  448  0.06%  2,440  0.08% 
18  Ophthalmology  153  0.02%  210  0.01% 
19  Oral surgery  33  0.00%  197  0.01% 
20  Orthopedic surgery  1,225  0.15%  2,638  0.08% 
22  Pathology  15  0.00%  159  0.00% 
24  Plastic surgery  28  0.00%  236  0.01% 
25  Physical medicine/rehab  52  0.01%  351  0.01% 
26  Psychiatry  31  0.00%  32  0.00% 
28  Colorectal surgery  33  0.00%  174  0.01% 
29  Pulmonary disease  2,216  0.27%  17,130  0.53% 
30  Diagnostic radiology  681,538  83.78%  1,985,698  61.99% 
31  Roentgenology, radiology**  0  0.00%  0  0.00% 
33  Thoracic surgery  1,206  0.15%  3,463  0.11% 
34  Urology  1,499  0.18%  78,782  2.46% 
36  Nuclear medicine  3,394  0.42%  9,819  0.31% 
37  Pediatric medicine  59  0.01%  360  0.01% 
38  Geriatric medicine  75  0.01%  265  0.01% 
39  Nephrology  337  0.04%  767  0.02% 
40  Hand surgery  1  0.00%  53  0.00% 
41  Optometry  0  0.00%  1  0.00% 
42  Cert nurse midwife**  0  0.00%  0  0.00% 
43  CRNA, anesth asst**  0  0.00%  0  0.00% 
44  Infectious disease  151  0.02%  1,374  0.04% 
45  Mammog screening center  21  0.00%  0  0.00% 
46  Endocrinology  514  0.06%  2,011  0.06% 
47  IDTF  0  0.00%  488,306  15.24% 
* As listed in  CMS documentation. 

** Specialty billed at least  one advanced imaging service between  1995  and  2005, even though counts  in 1995 and 2005 were zero. 

  OEI-01-06-00260   GROWTH IN  ADVANCED IMAGING  PAID  UNDER THE  MEDICARE PHYSICIAN FEE  SCHEDULE   22  A P P E N D I X ~ B  

Table 4 (continued):  Number and Percentage of CT Services Billed Under the MPFS, by Provider Specialty, in 1995  
and 2005 
Specialty   Number of CT   Percentage of CT   Number of CT   Percentage of CT  
Code  Specialty Description*  services, 1995  services, 1995  services, 2005  services, 2005 
48  Podiatry  16  0.00%  13  0.00% 
49 ASC     2 0 .00%   6 0 .00%  
50  Nurse practitioner  1  0.00%  2,000  0.06% 
54  Medical supply company  10  0.00%  0  0.00% 
58  Med supply w/pharmacist**  0  0.00%  0  0.00% 
59  Ambulance service supplier**  0  0.00%  0  0.00% 
60  Public hlth/welfare agency  5  0.00%  1  0.00% 
63  Portable X-ray supplier  4,720  0.58%  4,132  0.13% 
65  Physical therapist**  0  0.00%  0  0.00% 
66  Rheumatology  2,596  0.32%  2,665  0.08% 
68  Clinical psychologist**  0  0.00%  0  0.00% 
69  Clinical laboratory  102  0.01%  162  0.01% 
70  Multispec clinic/group  20,653  2.54%  2,014  0.06% 
71  Diagnostic X-ray**  0  0.00%  0  0.00% 
72  Diagnostic laboratory  0  0.00%  113  0.00% 
74  Occupational therapy  0  0.00%  7,173  0.22% 
75  Other medical care**  0  0.00%  0  0.00% 
76  Peripheral vascular disease  51  0.01%  78  0.00% 
77  Vascular surgery  210  0.03%  1,834  0.06% 
78  Cardiac surgery  42  0.01%  1,989  0.06% 
79  Addiction medicine**  8  0.00%  8  0.00% 
81  Critical care (intensivists)  32  0.00%  1,476  0.05% 
82  Hematology  116  0.01%  2,308  0.07% 
83  Hematology/oncology  8,005  0.98%  103,526  3.23% 
84  Preventive medicine  10  0.00%  4  0.00% 
85  Maxillofacial surgery  19  0.00%  34  0.00% 
86  Neuropsychiatry  49  0.01%  217  0.01% 
87  All other suppliers  13  0.00%  0  0.00% 
88  Unkn suppl/provider spclty  58  0.01%  3  0.00% 
89  Cert clin nurse specialist  0  0.00%  57  0.00% 
90  Medical oncology  2,396  0.29%  51,569  1.61% 
91  Surgical oncology  118  0.01%  533  0.02% 
92  Radiation oncology  4,663  0.57%  94,568  2.95% 
93  Emergency medicine  456  0.06%  3,716  0.12% 
94  Interventional radiology  18,171  2.23%  43,038  1.34% 
95  Indep physiological lab  5,409  0.66%  4  0.00% 
97  Physician assistant  0  0.00%  2,091  0.07% 
98  Gynecologist/oncologist  388  0.05%  4,551  0.14% 
99  Unknown physician specialty  1  0.00%  30  0.00%
   Total  813,541  100.00%  3,203,407  100.00% 
* As listed in CMS documentation. 

** Specialty billed at least one advanced imaging service between 1995 and 2005, even though counts in 1995 and 2005 were zero. 

  OEI-01-06-00260   GROWTH IN  ADVANCED IMAGING  PAID  UNDER THE  MEDICARE PHYSICIAN FEE  SCHEDULE   23  A P P E N D I X ~ B  

Table 5:  Number and Percentage  of MR Services Billed Under the MPFS, by Provider Specialty, in 1995 and 2005 
Specialty   Number of MR   Percentage of MR   Number of MR   Percentage of MR  
Code  Specialty Description*  services, 1995  services, 1995  services, 2005  services, 2005 
00  Carrier wide  17  0.00%  0  0.00% 
01  General practice  2,299  0.36%  7,634  0.28% 
02  General surgery  477  0.08%  1,488  0.05% 
03  Allergy/immunology  46  0.01%  118  0.00% 
04  Otolaryngology  194  0.03%  814  0.03% 
05  Anesthesiology  259  0.04%  4,537  0.17% 
06  Cardiology  142  0.02%  5,794  0.21% 
07  Dermatology  2  0.00%  919  0.03% 
08  Family practice  689  0.11%  21,651  0.79% 
09  Gynecology  0  0.00%  757  0.03% 
10  Gastroenterology  11  0.00%  332  0.01% 
11  Internal medicine  1,677  0.27%  28,191  1.03% 
12  Osteopathic therapy  3  0.00%  482  0.02% 
13  Neurology  24,741  3.93%  64,899  2.38% 
14  Neurosurgery  1,837  0.29%  20,703  0.76% 
16  Obstetrics/gynecology  93  0.01%  103  0.00% 
18  Ophthalmology  42  0.01%  314  0.01% 
19  Oral surgery  8  0.00%  0  0.00% 
20  Orthopedic surgery  3,616  0.57%  158,034  5.79% 
22  Pathology  2  0.00%  23  0.00% 
24  Plastic surgery  58  0.01%  392  0.01% 
25  Physical medicine/rehab  146  0.02%  8,973  0.33% 
26  Psychiatry  11  0.00%  232  0.01% 
28  Colorectal surgery  0  0.00%  4  0.00% 
29  Pulmonary disease  65  0.01%  850  0.03% 
30  Diagnostic radiology  522,124  82.88%  1,489,077  54.56% 
33  Thoracic surgery  192  0.03%  279  0.01% 
34  Urology  73  0.01%  678  0.02% 
36  Nuclear medicine  4,411  0.70%  4,100  0.15% 
37  Pediatric medicine  65  0.01%  350  0.01% 
38  Geriatric medicine  0  0.00%  214  0.01% 
39  Nephrology  9  0.00%  2,274  0.08% 
40  Hand surgery  1  0.00%  1,816  0.07% 
41  Optometry**  0  0.00%  0  0.00% 
42  Cert nurse midwife**  0  0.00%  0  0.00% 
43  CRNA, anesth asst**  0  0.00%  0  0.00% 
44  Infectious disease  11  0.00%  695  0.03% 
45  Mammog screening center**  0  0.00%  0  0.00% 
46  Endocrinology  19  0.00%  711  0.03% 
47  IDTF  0  0.00%  826,497  30.28% 
* As listed in CMS documentation. 

** Specialty billed at least one advanced imaging service between 1995 and 2005, even though counts in 1995 and 2005 were zero. 

  OEI-01-06-00260   GROWTH IN  ADVANCED IMAGING  PAID  UNDER THE  MEDICARE PHYSICIAN FEE  SCHEDULE   24  A P P E N D I X ~ B  

Table 5 (continued):  Number and  Percentage  of  MR Services Billed  Under the  MPFS, by Provider Specialty,  in 1995  
and 2005 
Specialty   Number of  MR   Percentage of MR   Number of MR   Percentage of MR  
Code  Specialty Description*  services, 1995  services, 1995  services, 2005  services, 2005 
48  Podiatry  111  0.02%  3,161  0.12% 
49 ASC     1 0 .00%   0 0 .00%  
50  Nurse practitioner  0  0.00%  901  0.03% 
51  Med supply w/orthotist  1,195  0.19%  0  0.00% 
54  Medical supply company  46  0.01%  0  0.00% 
58  Med supply w/pharmacist  1  0.00%  0  0.00% 
59  Ambulance service supplier**  0  0.00%  0  0.00% 
60  Public hlth/welfare agency  1  0.00%  1  0.00% 
63  Portable X-ray supplier  3,688  0.59%  48  0.00% 
65  Physical therapist  0  0.00%  2  0.00% 
66  Rheumatology  204  0.03%  25,002  0.92% 
68  Clinical psychologist**  0  0.00%  0  0.00% 
69  Clinical laboratory  2,476  0.39%  8  0.00% 
70  Multispec clinic/group  13,339  2.12%  1,384  0.05% 
71  Diagnostic X-ray**  0  0.00%  0  0.00% 
72  Diagnostic laboratory  0  0.00%  1,156  0.04% 
74  Occupational therapy  0  0.00%  1  0.00% 
75  Other medical care**  0  0.00%  0  0.00% 
76  Peripheral vascular  disease  0  0.00%  12  0.00% 
77  Vascular surgery  9  0.00%  61  0.00% 
78  Cardiac surgery  1  0.00%  14  0.00% 
79  Addiction medicine**  0  0.00%  0  0.00% 
80  Licensed clin social  worker**  0  0.00%  0  0.00% 
81  Critical care (intensivists)  0  0.00%  177  0.01% 
82  Hematology  14  0.00%  45  0.00% 
83  Hematology/oncology  191  0.03%  1,919  0.07% 
84  Preventive medicine  0  0.00%  200  0.01% 
85  Maxillofacial surgery  2  0.00%  2  0.00% 
86  Neuropsychiatry  0  0.00%  1  0.00% 
87  All other  suppliers  2  0.00%  0  0.00% 
88  Unkn suppl/provider  spclty  1,409  0.22%  1  0.00% 
89  Cert clin nurse specialist**  0  0.00%  0  0.00% 
90  Medical oncology  194  0.03%  412  0.02% 
91  Surgical oncology  0  0.00%  372  0.01% 
92  Radiation oncology  207  0.03%  7,093  0.26% 
93  Emergency medicine  92  0.01%  2,935  0.11% 
94  Interventional radiology  10,820  1.72%  28,404  1.04% 
95  Indep physiological lab  32,530  5.16%  2  0.00% 
97  Physician assistant  0  0.00%  1,684  0.06% 
98  Gynecologist/oncologist**  0  0.00%  0  0.00% 
99  Unknown physician  specialty  90  0.01%  388  0.01% 
   Total  629,963  100.00%  2,729,321  100.00% 
* As  listed in CMS documentation. 

**  Specialty billed at  least one advanced imaging service between 1995 and 2005, even though counts  in 1995 and 2005 were  zero. 

  OEI-01-06-00260   GROWTH IN  ADVANCED IMAGING  PAID  UNDER THE  MEDICARE PHYSICIAN FEE  SCHEDULE   25  A P P E N D I X ~ B  

Table 6:  Number and Percentage of PET Services Billed Under the MPFS, by Provider Specialty, in 1996 and 2005 
Specialty   Number of PET   Percentage of PET   Number of  PET   Percentage of  PET  
Code  Specialty Description*  services, 1996  services, 1996  services, 2005  services, 2005 
01  General practice  2  0.30%  173  0.08% 
02  General surgery  0  0.00%  185  0.08% 
03  Allergy/immunology  0  0.00%  2  0.00% 
04  Otolaryngology  0  0.00%  16  0.01% 
05  Anesthesiology  0  0.00%  77  0.03% 
06  Cardiology  602  90.25%  5,803  2.54% 
07  Dermatology  0  0.00%  27  0.01% 
08  Family practice  1  0.15%  185  0.08% 
10  Gastroenterology  0  0.00%  40  0.02% 
11  Internal medicine  6  0.90%  1,432  0.63% 
13  Neurology  0  0.00%  658  0.29% 
16  Obstetrics/gynecology  0  0.00%  4  0.00% 
18  Ophthalmology  0  0.00%  2  0.00% 
20  Orthopedic surgery**  0  0.00%  0  0.00% 
22  Pathology  0  0.00%  58  0.03% 
24  Plastic surgery  0  0.00%  2  0.00% 
25  Physical medicine/rehab**  0  0.00%  0  0.00% 
26  Psychiatry  0  0.00%  1  0.00% 
29  Pulmonary disease  0  0.00%  536  0.23% 
30  Diagnostic radiology  24  3.60%  81,695  35.76% 
33  Thoracic surgery  0  0.00%  13  0.01% 
34  Urology  3  0.45%  38  0.02% 
36  Nuclear medicine  9  1.35%  18,366  8.04% 
37  Pediatric medicine  1  0.15%  0  0.00% 
39  Nephrology  0  0.00%  17  0.01% 
43  CRNA, anesth  asst**  0  0.00%  0  0.00% 
44  Infectious disease  0  0.00%  2  0.00% 
45  Mammog screening center**  0  0.00%  0  0.00% 
46  Endocrinology  0  0.00%  56  0.02% 
47  IDTF  0  0.00%  88,347  38.67% 
48  Podiatry**  0  0.00%  0  0.00% 
50  Nurse practitioner  0  0.00%  2  0.00% 
63  Portable X-ray supplier  0  0.00%  266  0.12% 
65  Physical therapist  0  0.00%  2  0.00% 
66  Rheumatology  0  0.00%  2  0.00% 
69  Clinical laboratory  18  2.70%  0  0.00% 
70  Multispec clinic/group  0  0.00%  438  0.19% 
72  Diagnostic laboratory  0  0.00%  193  0.08% 
74  Occupational therapy  0  0.00%  538  0.24% 
78  Cardiac surgery  0  0.00%  1  0.00% 
* As listed  in CMS documentation. 

** Specialty billed at least one advanced imaging service between 1996 and 2005, even though counts in 1996 and 2005 were zero. 

  OEI-01-06-00260   GROWTH IN  ADVANCED IMAGING  PAID  UNDER THE  MEDICARE PHYSICIAN FEE  SCHEDULE   26  A P P E N D I X ~ B  

Table 6 (continued):   Number and Percentage of PET Services Billed Under  the MPFS, by  Provider Specialty, in  
1996 and 2005 
Specialty   Number of PET   Percentage of PET   Number of PET   Percentage of PET  
Code  Specialty Description*  services, 1996  services, 1996  services, 2005  services, 2005 
80  Licensed clin social worker**  0  0.00%  0  0.00% 
81  Critical care (intensivists)  0  0.00%  97  0.04% 
82  Hematology  0  0.00%  690  0.30% 
83  Hematology/oncology  1  0.15%  14,811  6.48% 
89  Cert  clin nurse specialist**  0  0.00%  0  0.00% 
90  Medical oncology  0  0.00%  6,272  2.75% 
91  Surgical oncology  0  0.00%  225  0.10% 
92  Radiation oncology  0  0.00%  5,917  2.59% 
93  Emergency medicine  0  0.00%  49  0.02% 
94  Interventional radiology  0  0.00%  917  0.40% 
95  Indep physiological lab**  0  0.00%  0  0.00% 
98  Gynecologist/oncologist  0  0.00%  285  0.12% 
99  Unknown physician specialty  0  0.00%  2  0.00%
   Total  667  100.00%  228,442  100.00% 
* As  listed in CMS documentation. 

**  Specialty billed at least one advanced imaging service between 1996 and 2005, even though counts in 1996 and 2005 were zero. 

  OEI-01-06-00260   GROWTH IN  ADVANCED IMAGING  PAID  UNDER THE  MEDICARE PHYSICIAN FEE  SCHEDULE   27  A P P E N D I X ~ B  

Table 7:   Growth  in Advanced Imaging  Utilization Rates, 1995 to 2005, by  
State 
Percentage growth in  
Services per 1,000   Services per 1,000  State utilization rate, 
State  beneficiaries, 1995  beneficiaries, 2005  1995 to 2005 
FL  85  326  282% 
AZ  78  291  273% 
NV  101  291  187% 
MD  64  275  328% 
NY  87  248  184% 
DE  74  240  225% 
NJ  74  240  226% 
DC  92  222  141% 
TX  45  209  368% 
WA  45  207  360% 
MN  57  192  237% 
CA  51  190  271% 
AL  29  182  526% 
PR  57  181  218% 
RI  40  176  344% 
AR  24  172  630% 
TN  32  164  408% 
LA  29  158  446% 
CT  52  158  205% 
WY  18  151  721% 
GA  34  140  317% 
KY  24  138  473% 
SC  17  137  682% 
AK  18  135  657% 
NC  27  131  391% 
KS  29  128  341% 
MA  32  124  287% 
IN  16  120  632% 
OK  23  120  420% 
PA  35  116  234% 
CO  17  110  536% 
ID  29  108  275% 
MO  25  107  331% 
OR  36  106  192% 
NM  19  105  459% 
MS  12  102  727% 
WI  29  97  238% 
OH  17  95  446% 
UT  8  90  1,064% 
IL  22  89  306% 
  OEI-01-06-00260   GROWTH IN  ADVANCED IMAGING  PAID  UNDER THE  MEDICARE PHYSICIAN FEE  SCHEDULE   28  A P P E N D I X ~ B  

Table 7 (continued):   Growth in Advanced Imaging Utilization Rates, 1995 
to 2005, by State 
Percentage growth  in 
Services per 1,000  Services per 1,000  State utilization rate, 
State  beneficiaries, 1995  beneficiaries, 2005  1995 to 2005 
IA  8  77  842% 
ME  31  76  143% 
MT  19  76  296% 
HI  9  73  689% 
VA  11  72  553% 
MI  22  71  229% 
ND  55  67  24% 
NE  14  67  364% 
SD  21  59  181% 
WV  10  40  297% 
NH  6  33  472% 
VT  1  8  597% 
  OEI-01-06-00260   GROWTH IN  ADVANCED IMAGING  PAID  UNDER THE  MEDICARE PHYSICIAN FEE  SCHEDULE   29    A P P E N D I X ~ C
  
 
  OEI-01-06-00260   GROWTH IN  ADVANCED IMAGING  PAID  UNDER THE  MEDICARE PHYSICIAN FEE  SCHEDULE   30  A P P E N D I X ~ C  

  OEI-01-06-00260   GROWTH IN  ADVANCED IMAGING  PAID  UNDER THE  MEDICARE PHYSICIAN FEE  SCHEDULE   31  A P P E N D I X ~ C  

  OEI-01-06-00260   GROWTH IN  ADVANCED IMAGING  PAID  UNDER THE  MEDICARE PHYSICIAN FEE  SCHEDULE   32   
A B PA A PN AECN CNEK KDRN NI OX2OWN  W~LD L E  AEPD DAG GGMEME EN NT TS S   
 
 
This report was prepared under the  direction of Joyce M. Greenleaf, 
Regional Inspector General for Evaluation and Inspections in the 
Boston regional office, and Russell W. Hereford, Deputy Regional 
Inspector General.  Kenneth R.  Price served as the team leader for  
this study. Other principal Office of Evaluation and Inspections staff 
from the Boston regional office who contributed  include Eric Kim and  
Amanda L. Pyles, and central office  staff includes Doris Jackson.   
 
 
  OEI-01-06-00260   GROWTH IN  ADVANCED IMAGING  PAID  UNDER THE  MEDICARE PHYSICIAN FEE  SCHEDULE   33