on October 14, 2010 |
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Topics: Imaging, Service Lines, Payer and Regulatory Policy, Revenue Cycle, Finance, Billing and Collections, CT
We've received a number of questions recently about interpretations for coronary CT angiography. What models allow cardiologists and radiologists to participate jointly? What models might limit Medicare compliance risks? We've covered this topic extensively in the past but wanted to revisit this issue based on renewed interest. This topic seems to be coming back to the fore given that more hospitals and health systems are employing more cardiologists.
We have heard several different proposed models for finding a way for cardiologists and radiologists to share in the professional interpretation and payment of cardiac imaging studies, and some of these may be risky when you consider Medicare billing compliance. First, the most Medicare-compliant model for CCTA interpretations is when only one physician reads and bills for the professional component of the exam. One survey of CCTA arrangements showed that 40 percent of respondents only have radiologists interpreting CCTA. At some institutions, cardiologists have not shown strong interest in participating in interpretations.
Of course, that's not that case everywhere.
If the hospital is open to cardiologists participating in the reads, this can create a difficult situation with the radiology group. If the radiology group is not open to shared interpretations, organizations may turn to what I refer to as the competitive model, where both specialties decide to compete for referrals. In these situations, the ordering physician must choose who they would like to read the exam, indicating their selection an order form or communicating their preference to the scheduler.
In cases where no preference is given, the exam would be placed into a pool or round robin of sorts, with those volumes distributed between the two specialties in some previously agreed upon manner. In cases where cardiologists are the interpreting physician, they would still need to get an over-read. They can either contract with the local radiology group or have these done via teleradiology.
For situations where cardiologists and radiologists are willing to work together on interpretations, the sticking point becomes how to structure a shared interpretations model that is technically compliant with Medicare billing rules. At issue here is the scope of the exam and requirements for interpretation. Typically, cardiologists can read the cardiac portion of the exam, but not the image data beyond the heart. As a result, an over-read is often necessary. Studies have shown that a significant portion of CCTA exams have significant findings outside of the heart, findings that cardiologists may miss if they are the sole interpreters. Also, if cardiologists read only the heart portion and bill Medicare for the read, they could be at risk because they are not interpreting the entirety of the exam. So there are both billing compliance and quality of care issues at hand here.
The survey I referenced above indicates that 37 percent of organizations have shared reading models, where physicians reassign professional billing to hospitals, the hospitals bill "globally" for both the technical and professional component, and then the hospitals pay out the physicians in some way. However, this is technically a noncompliant model, since the claim must still include the interpreting physician's NPI number. If that physician is listed as the physician performing the service, but in reality only performs a part of the read, then this could be a false claim situation. In another model, the cardiologist may read the cardiac portion, the radiologist read the non-cardiac portion, and then the two reports are merged. One physician then bills the payer, receives the professional fee, and then pays out the other physician a portion for the over-read. This may also be a non-compliant model due to the same issue.
There a couple of ways to structure shared interpretations that limit the risk of Medicare billing non-compliance.
Model #1: Preliminary "Wet" Reads
The cardiologist contracts with the radiologist to perform a preliminary read on the non-cardiac part of the CCTA exam. The radiologist provides a preliminary read of the exam, and the cardiologist then interprets the cardiac portion. The cardiologist bills for the professional interpretation (using the radiologist's report to interpret the entire CCTA study), and compensates the radiologist on a per-click basis.
Model #2: Quality Over-Reads
Either the cardiologist or radiologist would be the primary interpreting physician, and would bill for the professional interpretation. The billing physician would be responsible for interpreting the entirety of the image set, including both cardiac and non-cardiac portions. The interpreting physician would then refer the exam to the cardiologist for a quality over-read of the cardiac portion. Either the radiologist or the hospital would compensate the cardiologist on a per-click basis. The reverse of this model (the cardiologist as primary interpreting and billing physician, radiologist as over-read physician) can be used, but if the cardiologist is going to bill for the interpretation, they need to make an attempt to read the entirety of the images, otherwise it could be a false claims situation.
I should also point out that the state Medicare carrier or fiscal intermediary or Medicare administrative contractor (MAC) may also have ruled on this. For example, Highmark allows cardiologists to bill professionally for CCTA interpretations having only read the cardiac portion. However, some carriers only allow one physician to bill for one interpretation. So there is much local variation in how the local coverage determinations are applied, and the first step would be to check with your MAC or carrier (if no MAC yet) to see if they have any guidelines for interpretation
