Department of Health and Human Services 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
 
 
M P
EDICARE  AYMENTS FOR 
 
 
D R
IAGNOSTIC  ADIOLOGY 
 
SERV  ICES IN EMERGENCY 
 
D  
EPARTMENTS
 
 
 
 
 
Daniel R. Levinson  
Inspector General 
 
April 2011 
OEI-07-09-00450   
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OBJECTIVES
 
To determine the extent to which, in 2008, Medicare allowed claims for 
interpretation and reports of diagnostic radiology servicesspecifically 
computed tomography (CT), magnetic resonance imaging (MRI), and 
x-ray servicesperformed in hospital outpatient emergency 
departments that: 
1.  met Medicare documentation requirements, 
2.  were performed before beneficiaries left the hospital outpatient 
emergency departments, and 
3.  followed suggested documentation practice guidelines promoted by 
the American College of Radiology. 
BACKGROUND 
The Social Security Act and Centers for Medicare & Medicaid Services 
(CMS) regulations govern Medicare payments for all radiology services 
and require that services be medically necessary, have documentation to 
support the claims, and be ordered by physicians.   
We used the 2008 National Claims History File to identify 9.6 million 
Medicare claims ($215 million) for interpretation and reports of 
diagnostic radiology services for beneficiaries in hospital outpatient 
emergency departments.  Our review consisted of two simple random 
samples of claims:  a sample of 220 CT and MRI claims and a sample of 
220 x-ray claims.  We used a document review instrument to review all 
medical record documentation requested from facilities for each sampled 
claim.  We considered sampled claims erroneous if (1) documentation 
did not support that services were performed or (2) physicians orders 
were not present.  We also reviewed all interpretation and reports to 
determine whether they were performed during beneficiaries diagnoses 
and treatments in hospital outpatient emergency departments.  Finally, 
we reviewed interpretation and reports for all sampled claims for 
consistency with the American College of Radiologys suggested 
documentation practice guidelines. 
FINDINGS 
In 2008, Medicare claims for interpretation and reports of 19 percent 
of CTs and MRIs and 14 percent of x-rays in hospital outpatient 
emergency departments were erroneous because of insufficient 
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E X E C U T I V E   S U M M A R Y  
documentation.  Of the nearly 3 million claims allowed for 
interpretation and reports of CT and MRI services in hospital 
outpatient emergency departments in 2008, Medicare erroneously 
allowed 19 percent, amounting to nearly $29 million.  Of the nearly 
6.6 million claims allowed for interpretation and reports of x-ray 
services in hospital outpatient emergency departments in 2008, 
Medicare erroneously allowed 14 percent, amounting to nearly 
$9 million.  Physicians orders were not present in medical record 
documentation for 12 percent of CT and MRI interpretation and report 
claims, amounting to nearly $18 million.  Physicians orders were not 
present in medical record documentation for 9 percent of x-ray 
interpretation and report claims, amounting to $5 million.  
Documentation was not provided to support that interpretation and 
reports had been performed for 12 percent of CT and MRI claims, 
amounting to nearly $19 million, and 8 percent of x-ray claims, 
amounting to $5 million.   
In 2008, Medicare paid for interpretation and reports performed for 
16 percent of x-rays and 12 percent of CTs and MRIs after 
beneficiaries left hospital outpatient emergency departments;  CMS 
offers inconsistent payment guidance on the timing for 
interpretation.  CMSs guidance to contractors states that  contractors 
are to pay only for the interpretation performed at the same time as 
the diagnosis and treatment of the beneficiary in the emergency room if 
contractors receive multiple claims from, for example, the emergency 
room physician and the radiologist.  However, contractors are not 
required to confirm that the interpretation was performed while the 
beneficiary was in the emergency department if only one claim is 
received.  Medicare allowed more than $10 million (16 percent of claims) 
for interpretation and reports of x-rays that were performed after 
beneficiaries left hospital outpatient emergency departments and, based 
on OIGs prior work in this area, may not have contributed to 
beneficiaries diagnoses and treatments.  Of the $10 million, $7.5 million 
was for claims that had physicians orders and documentation to show 
that interpretation and reports had been performed.  In addition, 
Medicare allowed $19 million for interpretation and reports of CTs and 
MRIs that were performed after beneficiaries left hospital outpatient 
emergency departments.  Of the $19 million, $5.4 million was for claims 
that had physicians orders and documentation to show that 
interpretation and reports were performed.   
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E X E C U T I V E   S U M M A R Y  
Interpretation and reports for 71 percent of x-rays and 69 percent of 
CTs and MRIs in hospital outpatient emergency departments did not 
follow one or more suggested documentation practice guidelines 
promoted by the American College of Radiology.  Seventy-one 
percent of interpretation and reports for x-rays did not follow one or 
more suggested practice guidelines.  Sixty-nine percent of interpretation 
and reports for CTs and MRIs did not follow one or more suggested 
practice guidelines.  Documentation standards for interpretation and 
reports are essential for determining whether diagnostic radiology 
services contribute to beneficiaries diagnoses and treatments.   
RECOMMENDATIONS 
We recommend that CMS:   
Educate providers on the requirement to maintain documentation on 
submitted claims.   
Adopt a uniform policy for single and multiple claims for 
interpretation and reports of diagnostic radiology services to require 
that claimed services be contemporaneous or identify 
circumstances in which noncontemporaneous interpretations may 
contribute to the diagnosis and treatment of beneficiaries in hospital 
outpatient emergency departments. 
Take appropriate action on the erroneously allowed claims identified 
in our sample.  
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 
RESPONSE 
In its written comments on the report, CMS concurred with the first and 
third recommendations.  CMS did not concur with the second 
recommendation.    
In response to the first recommendation, CMS indicated that it will 
issue an educational article to the provider community to emphasize 
that documentation requirements will be enforced.  In response to the 
third recommendation, CMS indicated that upon receipt of the files from 
the Office of Inspector General, it will take appropriate action.  CMS 
will instruct the Medicare Administrative Contractors to consider this 
issue when prioritizing their medical review strategies or other 
interventions.   
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E X E C U T I V E   S U M M A R Y  
In response to the second recommendation, CMS indicated that it does 
not believe that a single billed interpretation must, in all cases, be 
contemporaneous with the beneficiarys diagnosis and treatment to 
contribute to that diagnosis and treatment.  A uniform policy requiring 
that interpretation and reports be contemporaneous with, or, if not 
contemporaneous, demonstrably contribute to the beneficiarys 
diagnosis and treatment could reduce unexplained complexity in what is 
already a complicated billing system for medical diagnostics.  We have 
revised the language of the second recommendation to clarify what we 
are recommending. 
 
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 T A B L E   O F   C O N T E N T S  
EX ECUT I VE  SUM M ARY  .....................................i 
 
 
I NT RO DU CT I O N  ............................................ 1 
 
 
F I NDI NG S  .................................................. 9 
In 2008, Medicare claims for interpretation and reports of  
19 percent of CTs and MRIs and 14 percent of x-rays in hospital 
outpatient emergency departments were erroneous because of 
insufficient documentation ................................ 9 
In 2008, Medicare paid for interpretation and reports performed 
for 16 percent of x-rays and 12 percent of CTs and MRIs after 
beneficiaries left hospital outpatient emergency departments ...  11 
Interpretation and reports for 71 percent of x-rays and 69 percent  
of CTs and MRIs in hospital outpatient emergency departments  
did not follow one or more suggested documentation practice 
guidelines promoted by the American College of Radiology .....  12 
 
RECO M M END AT I O N S  .....................................  15 
  Agency Comments and Office of Inspector General Response ....  16 
 
 
APP EN DI X ES  .............................................  18 
  A:  Document Review Instrument ..........................  18 
B:  Point Estimates and Confidence Intervals ................  19 
C:  Agency Comments ...................................  22 
 
 
ACKNO WL E DG M E N T S .....................................  24 
   
   
 I N T R O D U C T I O N  
OBJECTIVES 
To determine the extent to which, in 2008, Medicare allowed claims for 
interpretation and reports of diagnostic radiology servicesspecifically 
computed tomography (CT), magnetic resonance imaging (MRI), and 
x-ray servicesperformed in hospital outpatient emergency 
departments that: 
1.  met Medicare documentation requirements, 
2.  were performed before beneficiaries left the hospital outpatient 
emergency departments, and 
3.  followed suggested documentation practice guidelines promoted by 
the American College of Radiology. 
BACKGROUND 
In 2005, the Medicare Payment Advisory Commission testified before 
Congress about the increasing cost of diagnostic radiology services and 
the potential overuse of these services.  In 2009, the Senate Finance 
Committee released Transforming the Health Care Delivery  
System:  Proposals to Improve Patient Care and Reduce Health Care 
Costs, which indicated that the number of imaging services increased 
more than other Medicare physician services for the period under 
review. 
The Social Security Act (the Act) and Centers for Medicare & Medicaid 
Services (CMS) regulations govern Medicare payments for all services, 
including diagnostic radiology services,1 and require that these services 
be ordered by physicians, have documentation to support the claims, 
and be medically necessary.  The Act states that Medicare payments 
can be made when providers furnish appropriate information about the 
service (i.e., services are ordered by practitioners with clinical privileges 
or, consistent with State law, by other practitioners authorized by the 
medical staff and the governing body to order the services.  We refer to 
these practitioners as physicians in this report).2  Further, Medicare 
pays only for services considered to be reasonable and necessary.3  
 
1 For the purposes of this report, diagnostic radiology services include x-rays, CTs, and 
MRIs. 
2 Section 1833(e) of the Act; 42 CFR  482.26(b)(4). 
3 Section 1862(a)(1)(A) of the Act; 42 U.S.C.  1395y(a)(1). 
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Generally, reasonable and necessary services are those used to diagnose 
or treat illness or injury or to improve the functioning of a malformed 
body part.4   
Payment for Interpretation of Diagnostic Tests Furnished to Emergency 
Room Patients 
As a condition of fee schedule payment, services are required to 
contribute directly to the diagnosis or treatment of an individual 
beneficiary.5  When Medicare Administrative Contractors (MAC) receive 
a single claim for interpretation and report, they must presume that 
the one service billed was a service to the individual beneficiary rather 
than a quality control measure ...6  The Medicare Claims Processing 
Manual does not require contractors to confirm that interpretations 
were performed at the same time that the patient was in the emergency 
department or that the interpretation contributed to the diagnosis and 
treatment of the individual beneficiary when a single claim is 
submitted.   
However, when a MAC receive[s] multiple claims for the same 
interpretation [MACs must] pay for the interpretation and report that 
directly contributed to the diagnosis and treatment of the individual 
patient.7  The Medicare Claims Processing Manual goes on to state 
that MACs must pay for the interpretation billed by the . . . radiologist 
if the interpretation of the procedure is performed at the same time as 
the diagnosis and treatment of the beneficiary.  Any other 
reinterpretation of the original interpretation (e.g., one that was 
performed after the beneficiary has left the emergency department) 
should be treated and reimbursed through the diagnosis-related group 
as part of the hospitals quality assurance program.8    
 
4 Section 1862(a)(1)(A) of the Act; 42 U.S.C.  1395y(a)(1). 
5 42 CFR  415.102(a)(2). 
6 CMS, Medicare Claims Processing Manual (Internet-only manual), Pub. 100-04, ch. 13, 
 100.1.  Accessed at http://www.cms.gov/Manuals/IOM/list.asp on October 1, 2010. 
7 Ibid. 
8 A diagnosis-related group is a system developed as part of the prospective payment 
system to reimburse providers for treatment of similar diagnoses. 
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Medicare payments for diagnostic radiology services in hospital 
outpatient emergency departments have two components:  a technical 
component,9 paid by Part A; and a professional component, paid by 
Part B.  This report addresses only the professional component, which 
includes payments for physicians interpretations of images and reports 
on the clinical findings for inclusion in beneficiaries 
hospital-maintained medical records.10  Payments for the professional 
component are sent to interpreting physicians (i.e., emergency room 
physicians or radiologists).11   
After diagnostic radiology services are ordered by emergency 
department physicians, they can: 
  review diagnostic radiology images as part of evaluation and 
management (E/M) services for beneficiaries,12  
  perform interpretation and reports of diagnostic radiology services, 
and/or  
  consult with radiologists for their interpretation and reports on the 
findings for diagnostic radiology services.13   
Claims submitted for interpretations without complete written reports 
do not meet the conditions for payment.   
 
9 The technical component of diagnostic radiology services includes the administration 
and supervision of diagnostic equipment, supplies, and use of facilities.  CMS Medicare 
Claims Processing Manual (Internet-only manual), Pub. 100-04, ch. 13,  20.  Accessed at 
http://www.cms.gov/Manuals/IOM/list.asp on October 1, 2010.  
10 42 CFR  415.120(a). 
11 The physician should use modifier 26 to bill the professional component.  American 
Medical Association, Current Procedural Terminology, 2008. 
12 E/M services refer to visits and consultations furnished by physicians.  CMS, Medicare 
Claims Processing Manual (Internet-only manual), Pub. 100-04, ch. 13,  100.1.  Accessed at 
http://www.cms.gov/Manuals/IOM/list.asp on August 29, 2010.  Billing Medicare for a 
patient visit requires the selection of a Current Procedural Terminology (CPT) code that 
best represents the level of E/M service performed.  For example, there are five CPT codes 
(9928199285) that may be selected to bill for office or other outpatient visits for a new 
patient.  American Medical Association, Current Procedural Terminology, 2008. 
13 CMS, Medicare Claims Processing Manual (Internet-only manual), Pub. 100-04, 
ch. 13,  100.1.  Accessed at http://www.cms.gov/Manuals/IOM/list.asp on October 1, 2010. 
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I N T R O D U C T I O N  
Both emergency department physicians and radiologists may be paid for 
their interpretation and reports for CTs, MRIs, or x-rays.14  Medicare 
generally pays for only one interpretation and report for each diagnostic 
radiology service furnished to an emergency department patient.15   
Comprehensive Error Rate Testing 
CMS monitors the rates of inappropriate payments for Medicare 
fee-for-service claims through the Comprehensive Error Rate Testing 
(CERT) program.  CMS established the CERT program to randomly 
sample and review different types of service claims submitted to 
Medicare.  To calculate error rates, CERT staff randomly select claims 
for services each month from each contractor that processes Medicare 
claims.  CERT staff then request the medical record associated with 
each sampled claim from the provider that submitted the claim.  For 
2007, the CERT-listed paid claims error rates for diagnostic radiology 
services ranged from 0 to 7 percent, and provider compliance error rates 
ranged from 0 to 29 percent depending on the contractor.  Error rates 
for this report are based on a methodology different from the 
methodology used by CERT.   
Previous OIG Work 
The Office of Inspector General (OIG) issued a report in July 1993 
entitled Medicares Payment for Interpretations of Hospital Emergency 
Room X-rays (OEI-02-89-01490).  The report found that in 44 percent of 
the cases, radiologists reinterpreted sampled x-rays at least 1 day after 
the emergency departments discharged the patients.  These 
reinterpretations had no effect on the treatments provided to 
beneficiaries, and OIG recommended that these be treated and 
reimbursed as part of the hospitals quality assurance programs.   
METHODOLOGY  
Scope 
We evaluated whether claims allowed in 2008 for interpretation and 
reports of diagnostic radiology services performed in hospital outpatient 
 
14 The physician specialty (i.e., emergency department physician or radiologist) has no 
bearing upon which claim is paid.  CMS, Medicare Claims Processing Manual (Internet-only 
manual), Pub. 100-04, ch. 13,  100.1  Accessed at http://www.cms.gov/Manuals/IOM/list.asp 
on August 29, 2010.  Radiologists provided interpretation and reports for 97 percent of  
x-rays and 99 percent of CTs and MRIs for beneficiaries in hospital outpatient emergency 
departments. 
15 60 Fed. Reg. 6313063133 (Dec. 8, 1995). 
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I N T R O D U C T I O N  
emergency departments met two Medicare payment  
requirementsnamely, that:  (1) physicians orders for the services be 
present and (2) interpretation and reports be documented in the medical 
record.  Although contemporaneity is not a requirement, we determined 
the percentage of interpretations that were performed after 
beneficiaries left the hospital outpatient emergency department.  Based 
on prior OIG work in this area, we determined that interpretations 
performed after the patient was discharged from the emergency room 
may not have contributed to beneficiaries diagnosis and treatment.  We 
did not evaluate the proper coding or medical appropriateness of 
diagnostic radiology services associated with claimed interpretation and 
reports.  Finally, we determined whether the interpretation and reports 
followed suggested documentation practice guidelines promoted by the 
American College of Radiology, although we did not question the 
appropriateness of claims for services that did not follow these practice 
guidelines. 
Data Sources 
Medicare outpatient claims identification.  We used the 2008 National 
Claims History Standard Analytical File to identify 46 million Medicare 
outpatient claims allowed from 10.8 million hospital emergency 
department visits not resulting in inpatient stays.16, 17  From these 
46 million claims, we identified claims that (1) were for diagnostic 
radiology services;18 (2) included modifier 26, indicating the professional 
component; (3) included codes 22 or 23 for place of service, indicating 
outpatient or emergency department settings; and (4) included 
Healthcare Common Procedure Coding System (HCPCS) codes in the 
range of 70010 76140, indicating interpretation and reports of CTs, 

MRIs, and x-rays.19  This yielded a total of 9.6 million Medicare-allowed 
claims (for a total of $215 million) for interpretation and reports in 
hospital outpatient emergency departments.  Of these, Medicare 
allowed 3 million claims (for a total of $151 million) for interpretation 
 
16 We included claims with the following Ambulatory Payment Classifications:  00609, 
00613, 00614, 00615, or 00616. 
17 Allowed claims were for services performed up to 2 days after the beneficiarys 
discharge from the hospital outpatient emergency department because nearly all claims for 
interpretation and reports were created within 2 days of discharge. 
18 We included claims with the following Revenue Centers:  320, 321, 322, 323, 324, 329, 
350, 351, 359, 610, 611, 612, or 619. 
19 We consulted with a practicing board-certified radiologist to identify which HCPCS 
codes to include. 
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and reports of CTs and MRIs and 6.6 million claims (for a total of 
$64 million) for interpretation and reports for x-rays. 
Sample selection.  From the 9.6 million claims that we identified for 
interpretation and reports, we selected two simple random samples of 
claims for our review.  The first sample included 220 CT and MRI 
claims, and the second sample included 220 x-ray claims.  See Table 1 
for population and sample statistics.  
   
     Table 1:  Population and Sample Claims  
 
Stratum  Claims in Population  Sample Size 
 
CT and MRI claims  2,979,761*  220 
 
X-ray claims  6,618,103  220 
 
   Total  9,597,864  440 
 
* Of the 2,979,761 claims, 2,906,441 were for CTs and 73,320 were for MRIs. 
Source:  OIG analysis of claims data, 2010. 
 
Documentation request.  We requested medical record documentation 
from facilities that provided care to Medicare beneficiaries on the 
sampled dates of service.  This request included all documentation 
(including physicians orders) relevant to diagnostic radiology services, 
and interpretation and reports for those services provided in hospital 
outpatient emergency departments.   
To request medical documentation necessary to conduct this study, we 
contactedup to three times, if neededthe facilities where claimed 
services were provided.  Although we established contact with all 
facilities, we had five sampled claims for which none of the 
corresponding five facilities provided the documentation we requested.20  
We will forward these claims to CMS for appropriate action.  Because 
we made contact with these five facilities, we determined the five claims 
from these facilities to be undocumented for the purposes of our study.  
Therefore, we consider our response rate to be 100 percent.   
Analysis 
We created a document review instrument (see Appendix A) to guide 
our review of the medical records to ensure that all information was 
 
20 The OEI Medical Review Policy, June 2006, recommends treating sampled claims as 
undocumented/unsubstantiated services when contact was made with providers but OEI 
never received the corresponding medical records.   
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I N T R O D U C T I O N  
captured and that all reviews were consistent.  During development of 
the document review instrument, we conducted structured interviews 
with officials from the CMS central office and staff for all 10 MACs to 
ensure that we included relevant questions.  To pretest the document 
review instrument, we conducted documentation reviews of 24 medical 
records with staff from two hospitals, including radiologists, emergency 
department physicians, and compliance officers.21   
We reviewed documentation from medical records for all sampled claims 
to determine whether interpretation and reports (1) were ordered by 
physicians, (2) were present in the medical record, (3) were performed 
contemporaneously with (i.e., at the same time as) diagnoses and 
treatments of beneficiaries in the hospital outpatient emergency 
departments, and (4) followed suggested documentation practice 
guidelines promoted by the American College of Radiology.  To 
determine whether interpretation and reports were performed 
contemporaneously with beneficiaries diagnoses and treatments, we 
used the dictated dates and times on the interpretation and reports and 
evaluated physicians notes for clinical findings and/or consultations 
with the radiologists.   
We considered claims erroneous if (1) physicians orders were not part of 
the medical record documentation or (2) documentation did not support 
that interpretation and reports were performed.  Although lack of 
contemporaneity does not solely determine whether a claim is erroneous 
in instances in which a single claim is submitted, we sought to 
determine whether interpretation and reports were performed 
contemporaneously with beneficiaries diagnoses and treatments in 
hospital outpatient emergency departments.  To establish 
contemporaneity, we determined primarily whether interpretation and 
reports were dictated after beneficiaries left hospital outpatient 
emergency departments.  In the absence of documented dictation times 
on interpretation and reports, we looked for other documentation in the 
medical records that clearly indicated that information from the 
interpretation and reports was communicated after beneficiaries left 
hospital outpatient emergency departments.   
As an additional component of our medical record documentation 
review, we determined the extent to which interpretation and reports 
contained information consistent with suggested practice guidelines and 
 
21 These medical records were not included in our final sample. 
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I N T R O D U C T I O N  
technical standards for documentation for interpretation and reports 
from the American College of Radiology.  We used these suggested 
practice guidelines because CMS has not established minimum 
documentation standards for interpretation and reports.22  We were 
able to determine whether practice guidelines were followed for the 
194 CT and MRI claims and for the 202 x-ray claims that included 
documentation of the interpretation and reports.   
We projected our findings to the population of Medicare claims listed in 
Table 1.  See Appendix B for point estimates and confidence intervals.     
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspections approved by the Council of the Inspectors General on 
Integrity and Efficiency. 
 
22 The American College of Radiology Practice Guidelines and Technical Standards are 
educational tools designed to provide consensus-based, scientifically valid, and medically 
credible information to assist health care providers in delivering effective, efficient, 
consistent, and safe medical care.  Accessed at 
http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines.aspx on 
October 1, 2010.  Although OIG used industry-suggested documentation practice guidelines 
and technical standards in this study, it does not constitute endorsement or official Federal 
guidance.  
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 F I N D I N G S  
Of the 3 million claims allowed for 
In 2008, Medicare claims for interpretation and 
interpretation and reports of CT 
reports of 19 percent of CTs and MRIs and 
and MRI services in 2008, 
14 percent of x-rays in hospital outpatient 
Medicare erroneously allowed 
emergency departments were erroneous 
19 percent.  Medicare allowed 
because of insufficient documentation  
$29 million for interpretation and 
reports that did not have 
physicians orders as part of the medical record documentation and/or 
did not have documentation to support that interpretation and reports 
were performed (see Table 2).   
Table 2:  Erroneous Claims and Amounts for CT and MRI 
Interpretation and Reports 
Claims 
Type of Error  Allowed Amount  
(percentage) 
Did not have physicians orders as 
part of the medical record  11.8  $17,619,327 
documentation 
Did not have documentation to 
support that interpretation and  11.8  $18,591,135 
reports were performed 
      
   Total errors (gross)  23.6  $36,210,462 
(Overlapping errors)  4.5  $7,257,343* 
   Total errors (net)  19.1  $28,953,119 
* Relative precision exceeds 50 percent; the 95-percent confidence interval for this estimate is 
$2,602,939$11,911,747. 
Source:  OIG medical review of 2008 claims. 
 
Of the nearly 6.6 million claims allowed for interpretation and reports of 
x-ray services in 2008, Medicare erroneously allowed 14 percent.  
Medicare allowed almost $9 million for interpretation and reports that 
did not have physicians orders as part of the medical record 
documentation or did not have documentation to support that 
interpretation and reports were performed (see Table 3). 
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F I N D I N G S  
Table 3:  Erroneous Claims and Amounts for X-Ray  
Interpretation and Reports  
Claims 
Type of Error  Allowed Amount  
(percentage) 
Did not have physicians orders as 
part of the medical record  8.6  $5,448,504 
documentation 
Did not have documentation to 
support that interpretation and  8.2  $5,418,121  
reports were performed 
        
   Total errors (gross)  16.8  $10,866,624 
(Overlapping errors)  2.7  $1,889,468* 
   Total errors (net)  14.1  $8,977,156 
*Relative precision exceeds 50 percent; the 95-percent confidence interval for this estimate is 
$361,541$3,417,396. 
Source:  OIG medical review of 2008 claims. 
 
Physicians orders were not present in medical record documentation for 
12 percent of CT and MRI claims and 9 percent of x-ray claims 
Medicare allowed almost $18 million for interpretation and report 
claims of CTs and MRIs not supported by documented physicians 
orders.  Medicare allowed $5 million for interpretation and report 
claims of x-rays that did not have documented physicians orders.  As a 
condition for Medicare payment for these services, medical records must 
include documented physicians orders.   
Documentation was not provided to support that interpretation and reports 
were performed for 12 percent of CT and MRI claims and 8 percent of x-ray 
claims 
Medicare allowed almost $19 million for undocumented interpretation 
and reports of CTs and MRIs.  Medicare allowed $5 million for 
undocumented interpretation and reports of x-rays.  The Act states that 
as a condition for Medicare payment, providers must furnish 
appropriate information about the service (i.e., documentation to 
support that the service was performed).   
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F I N D I N G S  
In 2008, Medicare paid for interpretation and 
CMSs guidance on 
reports performed for 16 percent of x-rays and  payment for 
12 percent of CTs and MRIs after beneficiaries  interpretation of 
left emergency departments   diagnostic tests 
furnished to 
 
emergency room patients offers inconsistent direction regarding 
  whether interpretations are payable only if they were performed while 
patients were in the emergency room.   
According to CMS guidance, if claims processing contractors receive 
multiple billing claims from, for example, the emergency room physician 
and the radiologist, contractors are to pay only for the interpretation 
performed at the same time as the diagnosis and treatment of the 
beneficiary in the emergency room.  However, if only one claim is 
received, contractors are not required to confirm that the interpretation 
was performed while the beneficiary was in the emergency 
department.23      
Interpretation and reports for 16 percent of x-rays were performed after 
beneficiaries left hospital outpatient emergency departments 
Medicare allowed more than $10 million for interpretation and reports 
of x-rays that were performed after beneficiaries left hospital outpatient 
emergency departments.  These interpretations may not have 
contributed to the diagnosis and treatment of beneficiaries, given prior 
OIG work questioning the value of interpretations performed after 
patients were discharged from the emergency room.  We identified more 
than $7.5 million of these claims that did not overlap with the erroneous 
payments previously described in Table 3.  In one example, a 
beneficiary was discharged with the emergency department physician 
indicating a possible fibular head fracture.  However, documentation 
indicated that the radiologists interpretation and report was not 
performed until the following day.  In another example, the beneficiary 
was discharged from the hospital at 9:53 p.m., but the x-ray was not 
interpreted until 9:45 a.m. the following day.   
For 25 percent of x-ray claims, contemporaneity was difficult to 
establish because documentation in the medical record on dictation 
times was incomplete.  In one medical record, the emergency 
department notes included an interpretation of a chest x-ray; however, 
 
23 CMS, Medicare Claims Processing Manual (Internet-only manual), Pub. 100-04, ch. 
13,  100.1.  Accessed at  http://www.cms.gov/Manuals/IOM/list.asp on October 1, 2010. 
  OEI-07-09-00450  MEDICARE PAYMENTS FOR DIAGNOSTIC RADIOLOGY SERVICES IN EMERGENCY DEPARTMENTS  11    
   
F I N D I N G S  
the record said:  [T]he radiologist will read this later.  If there is any 
significance to that, we will notify the patient.  This documentation 
suggests that the treating physician was preparing to discharge the 
beneficiary prior to receiving the report from radiology.  Although the 
final interpretation and report was included in the medical record and 
was dictated on the same day as the beneficiarys emergency room visit, 
it was difficult to determine whether the radiologist verbally 
communicated the interpretation and report to the treating physician 
prior to discharge.     
Interpretation and reports for 12 percent of CTs and MRIs were performed 
after beneficiaries left hospital outpatient emergency departments 
Medicare allowed more than $19 million for interpretation and reports 
of CTs and MRIs that were performed after beneficiaries left hospital 
outpatient emergency departments.  Presumably, these interpretation 
and reports did not contribute to beneficiaries diagnoses and 
treatments.  We identified $5.4 million of these claims that did not 
overlap with the erroneous payments previously described in Table 2.  
For 27 percent of CT and MRI claims, contemporaneity was difficult to 
establish because documentation in the medical record on dictation 
times was incomplete.   
 
Interpretation and reports for 71 percent of  Of the 9.6 million x-ray, CT, and 
x-rays and 69 percent of CTs and MRIs in  MRI claims allowed, 
interpretation and reports did not 
hospital outpatient emergency departments did 
follow suggested documentation 
not follow one or more suggested 
practice guidelines for 71 percent 
documentation practice guidelines promoted by 
of x-ray claims and 69 percent of 
the American College of Radiology  
CT and MRI claims.  At the time 
of our review, CMS had not 
established minimum documentation standards for interpretation and 
reports of diagnostic radiology services.  However, the American College 
of Radiology provides suggested practice guidelines for documentation of 
interpretation and reports as an educational tool to help practitioners 
deliver effective, efficient, consistent, and safe medical care.  While the 
American College of Radiology indicates that these guidelines are not 
inflexible rules or practice requirements and are not intended to 
establish a legal standard of care, we used some of these practice 
guidelines, specifically dictation date and time, when available, to 
establish whether interpretation and reports contributed to diagnoses 
and treatments through contemporaneity. 
  OEI-07-09-00450  MEDICARE PAYMENTS FOR DIAGNOSTIC RADIOLOGY SERVICES IN EMERGENCY DEPARTMENTS  12    
   
FFF III NNN DDD III NNN GGG SSS    
Seventy-one percent of interpretation and reports for x-rays did not follow 
one or more suggested practice guidelines for documentation 
Seventy-one percent of interpretation and reports for x-rays did not 
follow one or more suggested practice guidelines (see Table 4).  Although 
following these practice guidelines is not required, the dictation date 
and time are essential to establish contemporaneity and to establish 
that these interpretation and reports were performed while 
beneficiaries were in hospital outpatient emergency departments.  The 
time of dictation was missing from 25 percent of interpretation and 
reports, and the date of dictation was missing from 18 percent of 
interpretation and reports.  In certain instances, we had to rely on other 
documentation to establish contemporaneity.  For example, notes in 
medical records may have indicated that interpretation and reports 
were communicated by the radiologists to the treating emergency 
department physicians while beneficiaries were in hospital outpatient 
emergency departments.  
Table 4:  American College of Radiology Practice Guidelines 
for X-Rays 
   Percentage of Interpretation and 
  Reports for X-Rays That Did Not 
Practice Guidelines 
Follow Suggested Practice Guidelines 
 
(n=202) 
 
Time examination performed  48.5 
T ime report dictated  24.8 
D ate report dictated  18.3 
R eferring physician  14.9 
D ate/time report transcribed   9.9 
D ate examination performed  1.0 
T ype of examination performed  0.5 
Name of interpreting physician  0.5 
 
Procedures and materials  0.5 
 
Beneficiary identifier  0.0 
 
Findings, limitations, and clinical issues  0.0 
 
Diagnosis, if relevant  0.0 
 
Missing at least one practice guideline  71.3 
 
Source:  OIG analysis of claims data, 2010. 
 
  OEI-07-09-00450  MEDICARE PAYMENTS FOR DIAGNOSTIC RADIOLOGY SERVICES IN EMERGENCY DEPARTMENTS  13    
   
F I N D I N G S  
Sixty-nine percent of interpretation and reports for CTs and MRIs did not 
follow one or more suggested practice guidelines for documentation 
Sixty-nine percent of interpretation and reports for CTs and MRIs did 
not follow one or more suggested practice guidelines (see Table 5).  
Although following these practice guidelines is not required, dictation 
date and time are critical to establishing that the results of the 
interpretation and report are communicated in a timely manner to the 
treating physician in the emergency department.  The time of dictation 
was missing from 27 percent of interpretation and reports, and the date 
of dictation was missing from 18 percent of interpretation and reports.  
However, as with interpretation and reports for x-rays, we relied on 
other documentation to establish contemporaneity. 
Table 5:  American College of Radiology Practice Guidelines 
for CTs and MRIs 
 
Percentage of Interpretation and 
 
Reports for CTs and MRIs That Did 
P ractice Guidelines 
Not Follow Suggested Practice 
 
Guidelines (n=194) 
 
Time examination performed  45.4 
 
Time report dictated  26.8 
 
Date report dictated  18.0 
 
Date/time report transcribed   12.9 
 
Referring physician  9.8 
 
Beneficiary identifier  1.0 
 
Date examination performed  1.0 
N ame of interpreting physician  1.0 
P rocedures and materials  1.0 
T ype of examination performed  0.5 
F indings, limitations, and clinical issues  0.5 
D iagnosis, if relevant  0.5 
M issing at least one practice guideline  68.6 
S ource:  OIG analysis of claims data, 2010. 
  OEI-07-09-00450  MEDICARE PAYMENTS FOR DIAGNOSTIC RADIOLOGY SERVICES IN EMERGENCY DEPARTMENTS  14    
   
 RR EE CC OO MM MM EE NN DD AA TT II OO NN SS   
In 2008, Medicare erroneously allowed 19 percent of claims for CT and 
MRI interpretation and reports in hospital outpatient emergency 
departments, amounting to nearly $29 million for interpretation and 
reports that were not documented and/or not ordered by physicians.  
Medicare erroneously allowed 14 percent of claims for x-ray 
interpretation and reports in hospital outpatient emergency 
departments, amounting to nearly $9 million.  These claims were 
erroneous because they were not documented and/or were not ordered 
by physicians.  CMS guidance is inconsistent regarding whether 
diagnostic radiology interpretations are payable only if they were 
performed while patients were in the emergency room.  We found that 
16 percent of interpretation and reports for x-rays and 12 percent of 
interpretation and reports for CTs and MRIs were provided after 
beneficiaries left hospital outpatient emergency departments.  Prior 
OIG work has questioned whether radiologists interpretations of x-rays 
after patients are discharged from the emergency room contributed to 
patient care.   
Therefore, we recommend that CMS:   
Educate providers on the requirement to maintain documentation on 
submitted claims  
CMS should remind providers of the requirement for documentation to 
support claims for payment.  This could include reminding providers 
about the need for the medical record documentation to include 
(1) physicians orders to support diagnostic radiology services performed 
and (2) complete interpretation and reports. 
Adopt a uniform policy for single and multiple claims for interpretation 
and reports of diagnostic radiology services to require that claimed 
services be contemporaneous or identify circumstances in which 
noncontemporaneous interpretations may contribute to the diagnosis and 
treatment of beneficiaries in hospital outpatient emergency departments  
CMS should adopt a clear and uniform policy that requires paid claims 
to be contemporaneous and to contribute to the diagnosis and treatment 
of beneficiaries in hospital outpatient emergency departments 
regardless of whether a single claim or multiple claims are submitted.  
A uniform policy requiring that interpretation and reports be 
contemporaneous with, or, if not contemporaneous, demonstrably 
contribute to the beneficiarys diagnosis and treatment could reduce 
unexplained complexity in what is already a complicated billing system 
for medical diagnostics.    
  OEI-07-09-00450  MEDICARE PAYMENTS FOR DIAGNOSTIC RADIOLOGY SERVICES IN EMERGENCY DEPARTMENTS  15    
   
R E C O M M E N D A T I O N S  
We understand, however, that diagnosis and treatment may be 
informed by interpretation of the radiology services after emergency 
department encounters.  As such, CMS should clearly define exceptions 
for which noncontemporaneous interpretations may contribute to the 
diagnosis and treatment of patients after they leave the emergency 
department.  As one possibility, CMS may wish to consider requiring 
modifiers to track instances in which emergency department diagnostic 
interpretations were performed after patients were discharged from 
emergency department care.   
Take appropriate action on the erroneously allowed claims identified in our 
sample 
We will forward information on the erroneously allowed claims 
identified in our sample to CMS in a separate memorandum.   
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 
RESPONSE 
In its written comments on the report, CMS concurred with the first and 
third recommendations.  CMS did not concur with the second 
recommendation. 
CMS stated that it would continue to monitor and refine its oversight of 
diagnostic radiology services.  In addition, CMS will request a meeting 
with the American College of Radiology to review its suggested practice 
guidelines for the documentation of interpretation and reports of CTs, 
MRIs, and x-rays administered to patients in outpatient emergency 
departments. 
In response to the first recommendation, CMS indicated that it will 
issue an educational article to the provider community to emphasize 
that documentation requirements will be enforced.   
In response to the third recommendation, CMS indicated that upon 
receipt of the files from OIG, it will take appropriate action, including 
forwarding the list of questionable claims to the Recovery Audit 
Contractor and MACs.  CMS will instruct the MACs to consider this 
issue when prioritizing their medical review strategies or other 
interventions. 
In response to the second recommendation, CMS did not concur.  CMS 
indicated that it does not believe that a single billed interpretation 
must, in all cases, be contemporaneous with the beneficiarys diagnosis 
and treatment to contribute to that diagnosis and treatment.  CMS 
  OEI-07-09-00450  MEDICARE PAYMENTS FOR DIAGNOSTIC RADIOLOGY SERVICES IN EMERGENCY DEPARTMENTS  16    
   
R E C O M M E N D A T I O N S  
further indicated that continued diagnosis and treatment can extend 
beyond the emergency encounter to other followup settings.   
We agree that diagnosis and treatment may extend to other settings 
subsequent to the emergency department encounter.  We maintain, 
however, that payment rules should uniformly require that an 
interpretation and report on an emergency department x-ray be 
contemporaneous with the beneficiarys diagnosis and treatment.  Or, if 
interpretations are not contemporaneous, they should satisfy some 
other criteria demonstrating the interpretations contribution to patient 
care.  CMSs current payment policy applies requirements 
inconsistently in different situations.  When a MAC receives multiple 
claims for the interpretation and report of an emergency department 
x-ray, it pays only for the interpretation and report that was 
contemporaneous with, and directly contributed to, the diagnosis and 
treatment of the beneficiary.  Any other interpretation and report is 
treated as part of the hospitals quality assurance program.  In contrast, 
when a MAC receives only a single interpretation and report claim in 
connection with an emergency department x-ray, current policy drops 
the requirement for contemporaneity and contribution altogether.  The 
MAC must presume that the one service billed was a medical service to 
the individual and not quality assurance and pays the claim if it 
otherwise meets any applicable reasonable and necessary test.  This 
inconsistency is not explained, nor do we believe the underlying 
rationale is obvious.  We have revised the language of the second 
recommendation to clarify what we are recommending. 
The full text of CMSs comments can be found in Appendix C. 
  OEI-07-09-00450  MEDICARE PAYMENTS FOR DIAGNOSTIC RADIOLOGY SERVICES IN EMERGENCY DEPARTMENTS  17    
   
 A P P E N D I X   ~   A  
 
Document  A:  Document Review Instrument
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 A P P E N D I X   ~   B  
Table B:  Point Estimates and Confidence Intervals 
Sample  Point  95-Percent 
Description 
Size (n)  Estimate  Confidence Interval 
Percentage of allowed claims lacking documented physicians orders for interpretation 
and reports of computed tomography (CT) and magnetic resonance imaging (MRI)  220  11.8  7.516.1 
Allowed amount of claims lacking documented physicians orders for interpretation and 
reports of CTs and MRIs  220  $17,619,327  $10,954,812$24,283,841 
Percentage of allowed claims for interpretation and reports for CTs and MRIs that were  
not documented  220  11.8  7.516.1 
Allowed amount of claims for interpretation and reports for CTs and MRIs that were  
not documented  220  $18,591,135  $11,620,055$25,562,216 
Percentage of allowed claims for CTs and MRIs that were not documented or lacked 
physicians orders (gross)  220  23.6  16.730.6 
Allowed amount of claims for CTs and MRIs that were not documented or lacked  
physicians orders (gross)  220  $36,210,462  $24,959,322$47,461,602 
Percentage of allowed claims for CTs and MRIs that were not documented or lacked  
physicians orders (overlapping)  220  4.5  1.87.3 
Allowed amount of claims for CTs and MRIs that were not documented or lacked 
physicians orders (overlapping)  220  $7,257,343  $2,602,939$11,911,747 
Percentage of allowed claims for CTs and MRIs that were not documented or lacked  
physicians orders (net)  220  19.1  13.924.3 
Allowed amount of claims for CTs and MRIs with no documented physicians orders or  
having undocumented interpretation and reports (net)  220  $28,953,119  $20,756,618$37,149,619 
Percentage of allowed claims with no documented physicians orders for interpretation 
and reports of x-rays  220  8.6  4.912.4 
Allowed amount of claims with no documented physicians orders for interpretation and 
reports of x-rays  220  $5,448,504  $3,054,537$7,842,471 
Percentage of allowed claims for interpretation and reports for x-rays that were not 
documented  220  8.2  4.511.8 
Allowed amount of claims for interpretation and reports for x-rays that were  
not documented  220  $5,418,121  $2,952,704$7,883,537 
Percentage of allowed claims for interpretation and reports for x-rays that were not 
documented or lacked physicians orders (gross)  220  16.8  10.922.7 
Allowed amount of claims for interpretation and reports for x-rays that were not 
documented or lacked physicians orders (gross)  220  $10,866,624  $6,922,264$14,810,985 
Percentage of allowed claims for interpretation and reports for x-rays that were not 
documented or lacked physicians orders (overlapping)  220  2.7  0.64.9 
Allowed amount of claims for interpretation and reports for x-rays that were not 
documented or lacked physicians orders (overlapping)  220  $1,889,468  $361,541$3,417,396 
Percentage of allowed claims for interpretation and reports for x-rays that were not 
documented or lacked physicians orders (net)  220  14.1  9.518.7 
       
continued on next page 
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A P P E N D I X   ~   B  
 
Table B:  Point Estimates and Confidence Intervals, Continued 
Sample  Point  95-Percent 
Description 
Size (n)  Estimate  Confidence Interval 
Allowed amount of claims for interpretation and reports for x-rays that were not 
documented or lacked physicians orders (net)  220  $8,977,156  $5,972,273$11,982,039 
Percentage of allowed claims for interpretation and reports for x-rays that were not 
contemporaneous with beneficiaries diagnoses and treatments in hospital outpatient  220  15.9  11.020.8 
emergency departments 
Allowed amount of claims for interpretation and reports for x-rays that were not 
contemporaneous with beneficiaries diagnoses and treatments in hospital outpatient  220  $10,170,821  $6,977,447$13,364,195 
emergency departments 
Allowed amount of claims for x-rays that were not contemporaneous and did not overlap 
with those claims with no documented physicians orders or having undocumented  220  $7,575,923  $4,754,169$10,397,677 
interpretation and reports 
Percentage of allowed claims for interpretation and reports for CTs and MRIs that were 
not contemporaneous with beneficiaries diagnoses and treatments in hospital  220  11.8  7.516.1 
outpatient emergency departments 
Allowed amount of claims for interpretation and reports for CTs and MRIs that were not 
contemporaneous with beneficiaries diagnoses and treatments in hospital outpatient  220  $19,334,315  $11,892,195$26,776,434 
emergency departments 
Allowed amount of claims for CTs and MRIs that were not contemporaneous and did not 
overlap with those claims with no documented physicians orders or having   220  $5,360,725  $838,027$9,883,424 
undocumented interpretation and reports 
Percentage of allowed claims for interpretation and reports for x-rays not following at  
least one suggested practice guideline promoted by the American College of Radiology  202  71.3  65.077.6 
X-ray interpretation and reports did not follow practice guideline for listing time  
examination was performed  202  48.5  41.655.5 
X-ray interpretation and reports did not follow practice guideline for listing time  
report was dictated  202  24.8  18.830.8 
X-ray interpretation and reports did not follow practice guideline for listing date  
report was dictated  202  18.3  12.923.7 
X-ray interpretation and reports did not follow practice guideline for listing referring  
physician  202  14.9  9.919.8 
X-ray interpretation and reports did not follow practice guideline for listing date/time  
report was transcribed   202  9.9  5.714.1 
X-ray interpretation and reports did not follow practice guideline for listing date  
examination was performed  202  1.0  0.23.9* 
X-ray interpretation and reports did not follow practice guideline for listing type of 
examination performed  202  0.5  0.13.5** 
X-ray interpretation and reports did not follow practice guideline for listing name of 
interpreting physician  202  0.5  0.13.5** 
X-ray interpretation and reports did not follow practice guideline for listing procedures  
and materials  202  0.5  0.13.5** 
continued on next page 
  OEI-07-09-00450  MEDICARE PAYMENTS FOR DIAGNOSTIC RADIOLOGY SERVICES IN EMERGENCY DEPARTMENTS  20    
   
A P P E N D I X   ~   B  
 
Table B:  Point Estimates and Confidence Intervals, Continued 
Sample  Point  95-Percent 
Description 
Size (n)  Estimate  Confidence Interval 
X-ray interpretation and reports did not follow practice guideline for listing beneficiary 
identifier  202  0.0  0.01.8* 
X-ray interpretation and reports did not follow practice guideline for listing findings, 
limitations, and clinical issues  202  0.0  0.01.8* 
X-ray interpretation and reports did not follow practice guideline for listing diagnosis, if 
relevant  202  0.0  0.01.8* 
Percentage of allowed claims for interpretation and reports for CTs and MRIs that did not  
follow at least one suggested practice guideline promoted by the American College of  194  68.6  62.075.1 
Radiology 
CT and MRI interpretation and reports did not follow practice guideline for listing time  
examination was performed  194  45.4  38.352.4 
CT and MRI interpretation and reports did not follow practice guideline for listing time  
report was dictated  194  26.8  20.533.1 
CT and MRI interpretation and reports did not follow practice guideline for listing date  
report was dictated  194  18.0  12.623.5 
CT and MRI interpretation and reports did not follow practice guideline for listing date/time  
report was transcribed   194  12.9  8.117.6 
CT and MRI interpretation and reports did not follow practice guideline for listing  
referring physician  194  9.8  5.614.0 
CT and MRI interpretation and reports did not follow practice guideline for listing  
beneficiary identifier  194  1.0  0.34.1** 
CT and MRI interpretation and reports did not follow practice guideline for listing date  
examination was performed  194  1.0  0.34.1** 
CT and MRI interpretation and reports did not follow practice guideline for listing name  
of interpreting physician  194  1.0  0.34.1** 
CT and MRI interpretation and reports did not follow practice guideline for listing 
procedures and materials  194  1.0  0.34.1** 
CT and MRI interpretation and reports did not follow practice guideline for listing type of 
examination performed  194  0.5  0.13.6** 
CT and MRI interpretation and reports did not follow practice guideline for listing findings, 
limitations, and clinical issues  194  0.5  0.13.6** 
CT and MRI interpretation and reports did not follow practice guideline for listing  
diagnosis, if relevant  194  0.5  0.13.6** 
*Confidence intervals were calculated with an exact method based on the binomial distribution because the standard method and logit transformation method cannot be 
 used when no sample units possess the characteristic measured. 
**Confidence intervals were calculated using the logit transformation because of poor coverage properties of the standard approximation method when a small number of 
sample units possess the characteristic of interest. 
Source:  Office of Inspector General analysis of claims data, 2010. 
 
 
  OEI-07-09-00450  MEDICARE PAYMENTS FOR DIAGNOSTIC RADIOLOGY SERVICES IN EMERGENCY DEPARTMENTS  21   x  c 
A  P  PEN  D 
Agency Comments 
Centers for Medicare & Medicaid Services 
Administrator 
DEC  2 22010  Washington, DC 20201
TO: 	 Daniel R. Levinson 
Inspector General 
FROM: 	 Donald M. Berwick, M.D. 
Administrator 
SUBJECT: 	 Office oflnspector General (OIG) Draft Report: "Medicare Payments for 
Diagnostic Radiology Services in Emergency Departments" (OEI-07-09-00450) 
Thank you for the opportunity to review and comment on the Office ofInspector General's 
(OIG) draft report, "Medicare Payments for Diagnostic Radiology Services in Emergency 
Departments." The Centers for Medicare & Medicaid Services (CMS) appreciates the time and 
resources OIGhas invested to determine the extent to which Medicare improperly paid claims 
for diagnostic radiology services. 
According to Medicare policy, emergency department physicians and radiologists may be paid 
for their interpretation and reports for computed tomography (CT), magnetic resonance imaging 
(MRI) and x-rays, Based on its review oftwo samples (220 claims each) of9.6 million 2008 
diagnostic radiology claims, OIG concluded that: 1) Medicare claims for interpretation and 
reports ofan estimated 19 percent ofCTs and MRls and an estimated 14 percent of x-rays in 
hospital outpatient emergency departments were improperly paid due to insufficient 
documentation; 2) Medicare paid for interpretation and reports made on an estimated 16 percent 
ofx-rays and an estimated 12 percent ofCTs and MRIs after beneficiaries left the hospital 
outpatient emergency departments; and 3) interpretations and reports for an estimated 71 percent 
of x-rays and an estimated 69 percent ofCTs and MRIs in hospital outpatient emergency 
departments did not follow one or more suggested documentation practice guidelines promoted 
by the American College of Radiology. 
The CMS will continue to monitor and refine our oversight ofdiagnostic radiology services. 
OIG made the following recommendations. 
OIG Recommendation 1 
Educate providers on the requirement to maintain documentation on the submitted claims. 
CMS Response 
The CMS concurs. CMS will issue an educational article to the provider community to 

emphasize that documentation requirements wilJ be enforced. 

OEI070900450  MEDICARE PAYMENTS FOR DIAGNOSTIC RADIOLOGY SERVICES IN EMERGENCY DEPARTMENTS 
22   
   
A P P E N D I X   ~   C  
  OEI-07-09-00450  MEDICARE PAYMENTS FOR DIAGNOSTIC RADIOLOGY SERVICES IN EMERGENCY DEPARTMENTS  23    
   
 A C K N O W L E D G M E N T S  
This report was prepared under the direction of Brian T. Pattison, 
Regional Inspector General for Evaluation and Inspections in the 
Kansas City regional office, and Deborah Walden, Deputy Regional 
Inspector General.   
Brian T. Whitley served as the team leader for this study.  Other 
principal Office of Evaluation and Inspections staff from the Kansas 
City regional office who contributed to the report include Dennis Tharp 
and Amber Meurs; central office staff who contributed include Kevin 
Manley, Kevin Farber, Julie Taitsman, and Jeff Weinstein.  
  OEI-07-09-00450  MEDICARE PAYMENTS FOR DIAGNOSTIC RADIOLOGY SERVICES IN EMERGENCY DEPARTMENTS  24    
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 practice guidelines: 
Office of Audit Services 
The Office of Audit Services (OAS) provides 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.  These evaluations focus on preventing fraud, waste, or abuse and promoting 
economy, efficiency, and effectiveness of departmental programs.  To promote impact, OEI 
reports also present practical recommendations for improving program operations.  
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations 
of fraud and misconduct related to HHS programs, operations, and beneficiaries.  With 
investigators working in all 50 States and the District of Columbia, OI utilizes its resources 
by actively coordinating with the Department of Justice and other Federal, State, and local 
law enforcement authorities.  The investigative efforts of OI often lead to criminal 
convictions, administrative sanctions, and/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 for OIGs internal operations.  OCIG represents OIG in all civil and 
administrative fraud and abuse cases involving HHS programs, including False Claims Act, 
program exclusion, and civil monetary penalty cases.  In connection with these cases, OCIG 
also negotiates and monitors corporate integrity agreements.  OCIG renders advisory 
opinions, issues compliance program guidance, publishes fraud alerts, and provides other 
guidance to the health care industry concerning the anti-kickback statute and other OIG 
enforcement authorities.