Reinterpretation of outside imaging challenging, but may be reimbursable

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 - Emergency Room, ER, hospital

The handling of outside imaging studies presents a dilemma for trauma centers that could disrupt workflow, raise costs and pose a medicolegal quandary if handled ineffectively, according to an article published online Feb. 14 in the Journal of the American College of Radiology.

In the article, authors Michael F. McNeeley, MD, of the University of Washington (UW) in Seattle, and colleagues explain how outside imaging studies are handled at Harborview Medical Center, one of the two hospitals affiliated with UW Medicine.

“In the absence of clear national or community standards, our emergency radiology section has developed algorithms for handling outside examinations to ensure complete diagnostic support for our clinical colleagues while minimizing unnecessary repeat imaging, undocumented interpretations, and redundant work that does not add diagnostic value,” wrote the authors.

Level I or II trauma centers may choose to reinterpret a patient’s study due to a number possible factors, explained McNeeley and colleagues. Studies from outside hospitals may arrive without a finalized, typewritten report, and even if it does, receiving clinicians may be wary of acting on the opinion of an unfamiliar radiologist.

Despite the fact that more than three-quarters of patients transferred to Harborview have already undergone at least one CT study prior to transfer, pretransfer imaging is often not actually required, according to the authors. The American College of Surgeons has said that imaging should not delay a transfer when local resources cannot support definitive care. However, many referring physicians may assume the receiving facility expects a thorough pretransfer imaging evaluation, while McNeeley and colleagues point out that insurance status and local culture also influence rates of pretransfer imaging.  

When a study does accompany a patient, radiologists must “balance the virtues of patient care and clinical collegiality against a natural reluctance to assume medicolegal responsibility for imaging studies without having control over the scan parameters and overall image quality and for which there may be no financial compensation,” wrote the authors.

The algorithm developed by Harborview’s emergency radiology section attempts to standardize the handling of outside image studies. Operator-dependent studies, such as ultrasound, catheter angiography and fluoroscopy, are reviewed at each radiologist’s discretion. Other studies are reviewed for technical adequacy and completeness of accompanying report. If the outside report is deemed sufficient, it is imported into the hospital’s PACS for archival purposes, while other cases are referred for completion imaging or reinterpretation. Outside studies are not reinterpreted if they are going to be repeated after the patient arrives, though the outside exam is typically referenced in the report of the subsequent examination, according to the authors.

“Our clinical colleagues have voiced appreciation that they are not forced to rely on outside reports that are suspected to be incomplete or inaccurate,” wrote McNeeley et al.

By providing formal reports on diagnostic opinions, the department can bill for interpretive services rendered, despite popular misconceptions that this is not possible for outside exams, according to the authors. There are documentation barriers, but by using the appropriate Current Procedural Terminology code modifier, costs may be recouped. The -26 modifier signifies only professional, not technical services were rendered, while Medicare may require the -77 modifier, which covers extenuating circumstances requiring a second interpretation.

“Our decision to avoid a standing order for the interpretation of outside imaging allows us to focus our efforts on activities that provide diagnostic value and steers us clear of any activities that could be construed as inappropriate self-referral,” wrote McNeeley and colleagues.