The CMS disagreed with a policy recommendation from HHS' inspector general that would affect when clinicians perform diagnostic radiology services, even after an inspector general's report found nearly $38 million in claims erroneously covered by Medicare in 2008.
The report states that 19%, or $29 million, of interpretation and reports for CT scans and MRIs, and 14%, or nearly $9 million, of X-rays conducted in hospital outpatient emergency departments are considered erroneous because of insufficient documentation. Either physicians' orders were not documented or documentation that would show interpretation and reports were performed was not available.
HHS’ inspector general recommended the CMS educate providers on documentation requirements for imaging services as well as send information from the “erroneously allowed” claims to recovery audit contractors, the CMS agreed.
The inspector general’s office also found that Medicare allowed claims for imaging procedures that were done after patients left emergency departments—16% of claims for interpretation and reports of X-rays and 12% of interpretation and reports of CT scans and MRIs.
In the report, the inspector general also found that the CMS “offers inconsistent payment guidance” even though the agency says that interpretation should be performed at the same time as a patient’s diagnosis and treatment in the emergency room. The inspector general asked the CMS to adopt a uniform policy for clinicians to conduct imaging services at the time of a patient’s diagnosis and treatment, or provide explanation of why services did not occur—a recommendation the CMS said it does not support.
In a Dec. 22 letter to Inspector General Daniel Levinson, CMS Administrator Dr. Donald Berwick wrote: “We do not agree that, in all cases, this single billed interpretation must be contemporaneous with the beneficiaries’ diagnosis and treatment in order to contribute to that diagnosis and treatment.”
Dr. Stephen Amis, professor and chair of the department of radiology at the Albert Einstein College of Medicine, said he was not surprised by the findings of the report, noting that “it’s a relatively common occurrence” for reports to be generated after the patient has left the emergency department.
Amis, who believes the current policy is a “reasonable” one, also said academic medical centers are increasingly staffing the radiology teams with a faculty member 24 hours a day rather than farming out services to outsourced radiology providers. He added that as the level of contemporaneous care increases, academic settings and private health systems should fully be in compliance over the next few years.
The trend in recent years has been “providing more and more contemporaneous coverage of emergency departments,” he said.