Department of Health and Human Services
 

OFFICE OF 

INSPECTOR GENERAL 

GROWTH IN ADVANCED IMAGING 


PAID UNDER THE MEDICARE 


PHYSICIAN FEE SCHEDULE
 

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. 
Δ EXECUTIVE SUMMARY 

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—magnetic 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. 

 O E I - 0 1 - 0 6 - 0 0 2 6 0 GROWTH IN ADVANCED I MAGING PAID UNDER THE MEDICARE P HYSICIAN F EE S CHEDULE i 
 

E X E CUTIVE S U MMAR Y 
 

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 State’s 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. 

O E I - 0 1 - 0 6 - 0 0 2 6 0 GROWTH IN ADVANCED I MAGING PAID UNDER THE MEDICARE P HYSICIAN F EE S CHEDULE ii 
EXECUTIVE SUMMARY 
 

AGENCY COMMENTS 

CMS concurred with our recommendation and shares OIG’s 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. 

 O E I - 0 1 - 0 6 - 0 0 2 6 0 GROWTH IN ADVANCED I MAGING PAID UNDER THE MEDICARE P HYSICIAN F EE S CHEDULE iii 
Δ TABLE OF CONTENTS 

EXECUTIVE SUMMARY ..................................... i 
 

INTRODUCTION ........................................... 1 
 

FINDINGS ................................................. 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 
 

RECOMMENDATION ...................................... 14 
 

APPENDIXES ............................................. 16 
 

A: Methodology........................................ 16 
 

B: Data Tables ........................................ 19 
 

C: Agency Comments ................................... 30 
 

ACKNOWLEDGMENTS .................................... 33 
 
INTRODUCTION 

 

 

 

Δ INTRODUCTION 

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 Medicare’s 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 Alzheimer’s disease 

and Parkinson’s 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 doctor’s 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. 

 O E I - 0 1 - 0 6 - 0 0 2 6 0 GROWTH IN ADVANCED I MAGING PAID UNDER THE MEDICARE P HYSICIAN F EE S CHEDULE 1 
 

 

 

INTRODUCTION 
 

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. 

 O E I - 0 1 - 0 6 - 0 0 2 6 0 GROWTH IN ADVANCED I MAGING PAID UNDER THE MEDICARE P HYSICIAN F EE S CHEDULE 2 
 

 

 

INTRODUCTION 
 

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 OIG’s report and other 

concerns with IDTFs as the rationale for establishing performance 

standards. CMS’s 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). 

 O E I - 0 1 - 0 6 - 0 0 2 6 0 GROWTH IN ADVANCED I MAGING PAID UNDER THE MEDICARE P HYSICIAN F EE S CHEDULE 3 
 

 

INTROD U C T U C T I O N I O N 
 

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 CMS’s 

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 CMS’s 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. 

O E I - 0 1 - 0 6 - 0 0 2 6 0 GROWTH IN ADVANCED I MAGING PAID UNDER THE MEDICARE P HYSICIAN F EE S CHEDULE 4 
INTRODUCTION 
 

Standards 

We conducted this study in accordance with the “Quality Standards for 

Inspections” issued by the President’s Council on Integrity and 

Efficiency and the Executive Council on Integrity and Efficiency. 

 O E I - 0 1 - 0 6 - 0 0 2 6 0 GROWTH IN ADVANCED I MAGING PAID UNDER THE MEDICARE P HYSICIAN F EE S CHEDULE 5 
 

Δ 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 paid 

under the MPFS made up nearly 

one-quarter of all advanced 

imaging paid by Medicare, 

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 

1.4 

$0.62 

1.5 

$0.66 

1.6 

$0.70 

1.8 

$0.84 

2.1 

$0.97 

2.5 

$1.21 

3.1 

$1.62 

3.8 

$1.87 

4.5 

$2.35 

5.4 

$2.94 

6.2 

$3.46 

6.0 $6 

$5

Allowed services (in millions) 

Allowed charges (in $billions) 

5.0 

4.0 $4

3.0 

2.0 

$3 

$2 

1.0 $1

0.0 $0 

1995 1996 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. 

 O E I - 0 1 - 0 6 - 0 0 2 6 0 GROWTH IN ADVANCED I MAGING PAID UNDER THE MEDICARE P HYSICIAN F EE S CHEDULE 6 
 

F I NDING S 

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 modality’s share of total growth in services with its share 

of total growth in charges. 

Chart 2a: Percentage of Total Growth in Allowed 

Services by Imaging Modality, 1995 to 2005
 

4.8% 

MR 

CT 

PET 

50.7% 

44.5% 

Chart 2b: Percentage of Total Growth in Allowed 

Charges by Imaging Modality, 1995 to 2005 

53.0% 

28.7% 

18.3% 

MR 

CT 

PET 

Source: OIG analysis of Part B data, 2007. 

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. 

O E I - 0 1 - 0 6 - 0 0 2 6 0 GROWTH IN ADVANCED I MAGING PAID UNDER THE MEDICARE P HYSICIAN F EE S CHEDULE 7 
 

 

FINDINGS 

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 

0 

6 

163 

42 

85 

24 

72 

18 

0 

25 

50 

75 

100 

125 

150 

175 

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 

Services per 1,000 Beneficiaries

All modalities 

CT 

MR 

PET 

Source: OIG analysis of Part B data, 2007. 

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 all advanced 

imaging services paid under the 

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.) 

 O E I - 0 1 - 0 6 - 0 0 2 6 0 GROWTH IN ADVANCED I MAGING PAID UNDER THE MEDICARE P HYSICIAN F EE S CHEDULE 8 
 

F I NDING S 

Table 1: Concentration of MPFS Advanced Imaging Services by 

Five Most Common Specialties, 1995 

Specialty 

Number of 

services 

Percentage of 

total services 

Diagnostic radiology 

Neurology 

IDTF* 

Multispecialty clinic/group 

Interventional radiology 

1,203,662 

39,203 

37,939 

33,992 

28,991 

83% 

3% 

3% 

2% 

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 

Specialty 

Number of 

services 

Percentage of 

total services 

Diagnostic radiology 

IDTF 

Orthopedic surgery 

Internal medicine 

Hematology/oncology 

3,556,470 

1,403,156 

160,672 

132,097 

120,256 

58% 

23% 

3% 

2% 

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. 

O E I - 0 1 - 0 6 - 0 0 2 6 0 GROWTH IN ADVANCED I MAGING PAID UNDER THE MEDICARE P HYSICIAN F EE S CHEDULE 9 
 

F I NDING S 

Chart 4: Advanced Imaging Services by Provider Specialty, 1995 and 2005 

0 

1,000,000 

2,000,000 

3,000,000 

4,000,000 

5,000,000 

6,000,000 

1995* 2005 

Services per year 

All other 

specialties 

IDTF 

Diagnostic 

radiology 

* 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 State’s 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 

O E I - 0 1 - 0 6 - 0 0 2 6 0 GROWTH IN ADVANCED I MAGING PAID UNDER THE MEDICARE P HYSICIAN F EE S CHEDULE 10 
FINDINGS 

northeastern States. See Figure 1 for growth in advanced imaging 

services per 1,000 beneficiaries and Figure 2 for utilization rates in 

2005. 

 O E I - 0 1 - 0 6 - 0 0 2 6 0 GROWTH IN ADVANCED I MAGING PAID UNDER THE MEDICARE P HYSICIAN F EE S CHEDULE 11 
 

FINDINGS 

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.) 

 O E I - 0 1 - 0 6 - 0 0 2 6 0 GROWTH IN ADVANCED I MAGING PAID UNDER THE MEDICARE P HYSICIAN F EE S CHEDULE 12 
 

F I NDING S 

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 1995, the MPFS covered 

77 different advanced imaging 

procedure codes. By 2005, this 

number had grown to 170, with 

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 

Procedure code Procedure description* 

Number of 

services 

Percentage of 

total services 

Number of 

years in the 

top 10 from 

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.
 

O E I - 0 1 - 0 6 - 0 0 2 6 0 GROWTH IN ADVANCED I MAGING PAID UNDER THE MEDICARE P HYSICIAN F EE S CHEDULE 13 
 

 

 

Δ CONCLUSION RECOMMENDATION 

The growth of advanced imaging in ambulatory settings—those for 

which Medicare payment is made under the MPFS—is 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 OIG’s 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. 

 O E I - 0 1 - 0 6 - 0 0 2 6 0 GROWTH IN ADVANCED I MAGING PAID UNDER THE MEDICARE P HYSICIAN F EE S CHEDULE 14 
 

RECOMMENDATION 

Medicare carriers regarding oversight of the new IDTF performance 

standards. 

Subsequent to OIG’s 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 OIG’s 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 CMS’s comments is provided in 

Appendix C. 

17 CMS, Transmittal 216, July 13, 2007. 

 O E I - 0 1 - 0 6 - 0 0 2 6 0 GROWTH IN ADVANCED I MAGING PAID UNDER THE MEDICARE P HYSICIAN F EE S CHEDULE 15 
RECOMMENDATION Δ APPENDIX~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 CMS’s 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 

 O E I - 0 1 - 0 6 - 0 0 2 6 0 GROWTH IN ADVANCED I MAGING PAID UNDER THE MEDICARE P HYSICIAN F EE S CHEDULE 16 
 

APPENDIX~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 CMS’s 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. 

 O E I - 0 1 - 0 6 - 0 0 2 6 0 GROWTH IN ADVANCED I MAGING PAID UNDER THE MEDICARE P HYSICIAN F EE S CHEDULE 17 
 

A P P E N D I X ~ A 

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. 

O E I - 0 1 - 0 6 - 0 0 2 6 0 GROWTH IN ADVANCED I MAGING PAID UNDER THE MEDICARE P HYSICIAN F EE S CHEDULE 18 
Δ APPENDIX~B 

Table 1: Growth in Allowed Services for Advanced Imaging Under the MPFS, by Year, 1995 to 2005 

Three modalities combined CT MR PET 

Year Allowed services 

Percentage 

change from 

previous year Allowed services 

Percentage 

change from 

previous year Allowed services 

Percentage 

change from 

previous year Allowed services 

Percentage 

change from 

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 

Year Allowed charges 

Percentage 

change from 

previous year Allowed charges 

Percentage 

change from 

previous year Allowed charges 

Percentage 

change from 

previous year Allowed charges 

Percentage 

change from 

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. 

 O E I - 0 1 - 0 6 - 0 0 2 6 0 GROWTH IN ADVANCED I MAGING PAID UNDER THE MEDICARE P HYSICIAN F EE S CHEDULE 19 
 

APPENDIX~B 

Table 3: Number and Percentage of Advanced Imaging Services Billed Under the MPFS, by Provider Specialty, in 

1995 and 2005 

Specialty 

Code Specialty Description* 

Number of advanced 

imaging services, 

1995 

Percentage of 

advanced imaging 

services, 1995 

Number of advanced 

imaging services, 

2005 

Percentage of 

advanced imaging 

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.
 

 O E I - 0 1 - 0 6 - 0 0 2 6 0 GROWTH IN ADVANCED I MAGING PAID UNDER THE MEDICARE P HYSICIAN F EE S CHEDULE 20 
 

APPENDIX~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.
 

 O E I - 0 1 - 0 6 - 0 0 2 6 0 GROWTH IN ADVANCED I MAGING PAID UNDER THE MEDICARE P HYSICIAN F EE S CHEDULE 21 
 

APPENDIX~B 

Table 4: Number and Percentage of CT Services Billed Under the MPFS, by Provider Specialty, in 1995 and 2005 

Specialty 

Code Specialty Description* 

Number of CT 

services, 1995 

Percentage of CT 

services, 1995 

Number of CT 

services, 2005 

Percentage of CT 

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.
 

 O E I - 0 1 - 0 6 - 0 0 2 6 0 GROWTH IN ADVANCED I MAGING PAID UNDER THE MEDICARE P HYSICIAN F EE S CHEDULE 22 
APPENDIX~B 

Table 4 (continued): Number and Percentage of CT Services Billed Under the MPFS, by Provider Specialty, in 1995 

and 2005 

Specialty 

Code Specialty Description* 

Number of CT 

services, 1995 

Percentage of CT 

services, 1995 

Number of CT 

services, 2005 

Percentage of CT 

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.
 

 O E I - 0 1 - 0 6 - 0 0 2 6 0 GROWTH IN ADVANCED I MAGING PAID UNDER THE MEDICARE P HYSICIAN F EE S CHEDULE 23 
APPENDIX~B 

Table 5: Number and Percentage of MR Services Billed Under the MPFS, by Provider Specialty, in 1995 and 2005 

Specialty 

Code Specialty Description* 

Number of MR 

services, 1995 

Percentage of MR 

services, 1995 

Number of MR 

services, 2005 

Percentage of MR 

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.
 

 O E I - 0 1 - 0 6 - 0 0 2 6 0 GROWTH IN ADVANCED I MAGING PAID UNDER THE MEDICARE P HYSICIAN F EE S CHEDULE 24 
 

 

 

APPENDIX~B 

Table 5 (continued): Number and Percentage of MR Services Billed Under the MPFS, by Provider Specialty, in 1995 

and 2005 

Specialty 

Code Specialty Description* 

Number of MR 

services, 1995 

Percentage of MR 

services, 1995 

Number of MR 

services, 2005 

Percentage of MR 

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.
 

 O E I - 0 1 - 0 6 - 0 0 2 6 0 GROWTH IN ADVANCED I MAGING PAID UNDER THE MEDICARE P HYSICIAN F EE S CHEDULE 25 
 

APPENDIX~B 

Table 6: Number and Percentage of PET Services Billed Under the MPFS, by Provider Specialty, in 1996 and 2005 

Specialty 

Code Specialty Description* 

Number of PET 

services, 1996 

Percentage of PET 

services, 1996 

Number of PET 

services, 2005 

Percentage of PET 

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.
 

 O E I - 0 1 - 0 6 - 0 0 2 6 0 GROWTH IN ADVANCED I MAGING PAID UNDER THE MEDICARE P HYSICIAN F EE S CHEDULE 26 
 

 

APPENDIX~B 

Table 6 (continued): Number and Percentage of PET Services Billed Under the MPFS, by Provider Specialty, in 

1996 and 2005 

Specialty 

Code Specialty Description* 

Number of PET 

services, 1996 

Percentage of PET 

services, 1996 

Number of PET 

services, 2005 

Percentage of PET 

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.
 

 O E I - 0 1 - 0 6 - 0 0 2 6 0 GROWTH IN ADVANCED I MAGING PAID UNDER THE MEDICARE P HYSICIAN F EE S CHEDULE 27 
 

APPENDIX~B 

Table 7: Growth in Advanced Imaging Utilization Rates, 1995 to 2005, by 

State 

State 

Services per 1,000 

beneficiaries, 1995 

Services per 1,000 

beneficiaries, 2005 

Percentage growth in 

State utilization rate, 

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% 

 O E I - 0 1 - 0 6 - 0 0 2 6 0 GROWTH IN ADVANCED I MAGING PAID UNDER THE MEDICARE P HYSICIAN F EE S CHEDULE 28 
 

APPENDIX~B 

Table 7 (continued): Growth in Advanced Imaging Utilization Rates, 1995 

to 2005, by State 

State 

Services per 1,000 

beneficiaries, 1995 

Services per 1,000 

beneficiaries, 2005 

Percentage growth in 

State utilization rate, 

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% 

 O E I - 0 1 - 0 6 - 0 0 2 6 0 GROWTH IN ADVANCED I MAGING PAID UNDER THE MEDICARE P HYSICIAN F EE S CHEDULE 29 
Δ APPENDIX~C 

 O E I - 0 1 - 0 6 - 0 0 2 6 0 GROWTH IN ADVANCED I MAGING PAID UNDER THE MEDICARE P HYSICIAN F EE S CHEDULE 30 
APPENDIX~C 

 O E I - 0 1 - 0 6 - 0 0 2 6 0 GROWTH IN ADVANCED I MAGING PAID UNDER THE MEDICARE P HYSICIAN F EE S CHEDULE 31 
APPENDIX~C 

 O E I - 0 1 - 0 6 - 0 0 2 6 0 GROWTH IN ADVANCED I MAGING PAID UNDER THE MEDICARE P HYSICIAN F EE S CHEDULE 32 
APPENDIX ~ A BANNER 2ND PAGE 

 

Δ ACKNOWLEDGMENTS ACKNOWLEDGMENTS 

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. 

 O E I - 0 1 - 0 6 - 0 0 2 6 0 GROWTH IN ADVANCED I MAGING PAID UNDER THE MEDICARE P HYSICIAN F EE S CHEDULE 33