GruntDoc ranted:

[Our] hospital where the radiology department has the ‘exclusive billing’ clause for radiologic services. Right now they don’t care if we use our US machine in the ED, but they do care if we bill (even though the ED uses different codes) because it interferes with their exclusivity.

As a different rant, I cannot figure out why we put up with waiting a day or more to have our plain-films over-read. Well, I have it figured out, and just wish I could pretend part of my job wasn’t important so I could do it when it’s convenient for me.

I won’t claim to be the most experienced voice in this field, but from what experience I have, this seems to be a common problem: radiologist groups who will or can not deliver real-time interpretation of plain films, due to high workload and staffing difficulty. Most do give readings of CTs and Ultrasounds, and deliver over-reads of plain x-rays, usually within 24 hours. But from our side of the fence, this creates huge operational problems in the ED — the massive amount of time spent reconciling the discrepancies between the ED docs’ original reads and the final radiologist’s report, the potential harm to patients, the pissed-off patients who had to be notified that an “error” had been made, the increased liability from even trivial discrepancies, etc.

As you might expect, it can prove difficult to convince the radiologists to give real-time reads on plain films, especially at night, since they are getting paid either way and it is hard to find docs to work between the hours of 11PM and 7AM. Hospital administration, though sympathetic, may claim they have have little power to compel the radiologists to come around. So many times the ED physicians suggest that since they are, for whatever reason, obligated to deliver care solely on the basis of their own interpretation of the X-rays, that they have provided the service to the patient, assumed the risk, and deserve the compensation.

Beware that when you raise this point, you are igniting a turf war. It’s one you can win, though, if you have the will and an adequate political base of support within the hospital. It is important to have defined your goals in advance: some ED groups see this as an important business opportunity and a significant source of revenue worth fighting for. Our philosophy, when we addressed this a few years back, was that we did not want to be reading the X-rays, that we wanted contemporaneous interpretations. So we play the role of “patient advocates,” arguing that the best care is a real-time reading of all radiographs by a radiologist. This is a nice tactic to take because it clearly puts you in the white hat, and I think is probably where most ED groups find themselves trending. But it is backed by a real threat that we could bill for the interpretations ourselves if this service is unavailable.

This threat has teeth because, on a routine basis, most payors, most notably Medicare, will only pay once for an X-ray interpretation. If only one bill is received, they pay it without question. If more than one provider attempts to bill for an ER study, the CMS policy is that the provider who performed the interpretation at the time care was delivered to the beneficiary is the individual who will be compensated. Though I have not heard of any OIG investigations on this matter, the implication is very clear that if the radiologists also attempt to submit a bill for payment, that practice would be at the least noncompliant and at the worst, fraudulent.

Similarly, I might suggest to GruntDoc’s hospital administrator that the radiology group’s “exclusive” contract for interpretive services is also noncompliant and possibly illegal since it would seem to prevent other physicians from billing for services legitimately rendered to beneficiaries.

The other major objection to ED physicians performing the primary reads of ED X-rays is QA, which is required under Medicare part A. The response to this is that it is simply not our problem — that is a hospital function. If the hospital has to pay the staff radiologists for QA over-reads on X-rays that the ED physicians have already billed out, the hospital may suddenly find that it has a dog in this fight and the pressure on the radiologists to provide timely interpretations may suddenly increase.

Either way, I view this as a win-win for the ED and well worth the effort to fight it out. Either you have the option of billing your own X-rays and the (modest) revenue that would accompany it, or you get real-time radiology reports on all your X-rays and the higher level of quality and security that comes with that service.

And by the way, every word I have written on this subject can be as easily applied to ECGs as well as to X-rays, except that real-time interpretations from cardiologists are much less useful or likely to occur.

#1 payout reason for EM docs? Missed fractures. (Not the biggest ticket, but the most common reason for settlement).

Funny, the exams that ‘really matter’ are the ones that my patient needs, not the ones you enjoy reading or that come out of fancy machines.

I have to guess you’re handling the radiology contract negotiations for your group.

Radiologists like to argue it both ways: their input is extraordinarily important to the process, and it doesn’t need to be done while the actual care is going on. Phoo.

GD–Are you sure that it is a day or more until your plain films are over-read? More likely they are read much sooner than that, but you don’t get a report as soon as you would like due to various non-radiology issues–transcription, distribution, etc. Of course you will not be completely satisfied until you have an on-site radiologist babysitting you 24/7. I am sure there are mechanisms at your hospital to get something read very quickly, but you would rather complain. I have an idea: Complain to administration about the situation! Get a new radiology group with better babysitters!

As a different rant, I cannot figure out why we put up with waiting a day or more to have our plain-films over-read. Well, I have it figured out, and just wish I could pretend part of my job wasn’t important so I could do it when it’s convenient for me.

I discovered this when I started doing lumbar discectomies and anterior cervical procedures in an ambulatory surgicenter which did not offer on-site radiology services and did not have digital Xray capability. I was reading my intraoperative films and felt I should get paid for it; the description of the operation does not include the reading of intra-operative films. The facility kept a copy of the report, I kept a copy in the patient’s office chart, and I kept the film at the office too. I always got paid. Of course there was no existing radiologist’s report, but once I knew HOW to bill, I then decided to issue supplementary reports on those Xrays that came in to my office (usually when a new patient came for a consult) when my interpretation was significantly different. I took care to state in my Consult that my opinion was different from that of the original reading radiologist as well as what my opinion was. I didn’t say anything in my Consult about issuing a separate Xray report; I just issued it separately and billed it with -26.
Always got paid.

The radiologists I use have been trained to give me the full Dicom file and not bother with jpg’s.

peace

SG

Some software allows you to control the amount of lossiness when saving an original image to JPEG. That might solve the problem and allow the use of standard JPEG viewing software, provided it can zoom in far enough. I’m not sure if that or anything else allows enough compression to get a set of several full-quality XRays onto one CD.

You might also be losing image details just from digitizing, even if the pictures are stored as full bitmaps. Digitizing breaks the image up into little blocks and assigns a single intensity number to each block. In some ways this is more accurate than the analog processes of film exposure and development, but it may obscure fine lines and subtle intensity differences that are recorded on film. You avoid that by overkill – by having pixels as small as one grain of silver on film, and by using enough bits per pixel to record intensity differences down to the scale of random variations in the photographic process. However, this overkill not only makes the camera or x-ray sensor much more expensive, but it greatly increases the file size.

I would feel a whole lot better the next time I go in for a radiograph if this discussion had been about images burned into a writeable DVD rather than CD-ROM…