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Fair-market approach to cardiac turf war proves problematic

Radiology Administrator's Compliance and Reimbursement Insider, February 1, 2007

Editor’s note: This is the second in a series regarding approaches to the cardiology/ radiology debate concerning the ownership of heart imaging techniques and reimbursement.

Noninvasive cardiac imaging has advanced dramatically in its efficacy and sophistication during recent years. Few people question the important and rapidly-expanding role that such imaging plays in the diagnosis and treatment of heart-related ailments.

Further, research demonstrates that noninvasive cardiac imaging could replace cardiac catheterization as the test of choice for patients with possible coronary artery blockages.

Average Americans see this as an advantage—both to their health and healthcare pocketbooks. Some people express exaltation for such technological advancements, but others see a dark day approaching.

Tools for noninvasive cardiac imaging historically belonged under radiologists’ rule—leaving invasive techniques under cardiologists’ command. However, with many invasive procedures heading for extinction, the struggle for control over heart imaging is increasing.

Many cardiologists have chosen to earn additional qualifications in imaging. With these qualifications behind them, they open the door to earning reimbursement for the professional component of such studies.

This leaves radiologists staring into the extinction abyss. Because without obtaining additional qualifications themselves, they cannot discount the idea of such a fate.

“It’s a balancing act that radiology needs to engage in,” said W. Kenneth Davis Jr., attorney with Katten Muchin Rosenman, LLP, in Chicago. Davis spoke during an audioconference presented by the Radiology Business Management Association in 2006.

“It’s part science, part art,” he said.

Struggling for interpretation

Radiologists typically analyze both the heart and the chest during a CTA study. However, radiologists do not have comprehensive training about the heart. Conversely, cardiologists do not have comprehensivetraining reading images, or in areas outside the heart.

Reimbursement codes for this procedure once included interpretation of the chest image with interpretation of the heart image. New category III codes separate out these for each procedure.

Regardless, for professional liability reasons, physicians should interpret the entire image—not just the heart portion. The question remains whether cardiologists even want to read CT or magnetic resonance studies not related to heart procedures.

Sometimes, the hospital management and contractual requirements prevent cardiologists from interpreting the nonheart portion without proper training.

And, according to Davis, there’s simply not enough incentive right now for them to acquire the additional credentialing.

Finding a fair market approach

In the meantime, many cardiologists and radiologists are seeking clinically principled, commercially reasonable fair market value approaches for collaboration.

But compliance problems arise when radiologists and cardiologists attempt to share responsibility for the professional component of the interpretation, said Davis.

Such joint approaches prompt legal questions that do not have clear answers. “There’s just not enough governmental guidance out there right now,” he said.

That may not be what radiologists want to hear, Davis added, but “it doesn’t need to be a battle.”

No one owns new technologies, he said.

Most noninvasive cardiac imaging studies represent ‘new’ or ‘found’ procedures—exams that neither profession traditionally owned. So it only makes sense for each side to share the spoils of technology’s discoveries, said Davis.

He believes that radiologists and cardiologists can work together without taking patients away from each other.

“When noninvasive cardiac imaging begins replacing certain cardiac catheterization procedures, it will be hard to argue that cardiologists should not at least have some role, if not the primary role, in the professional component,” he said.

Choosing options

Administrators attempting to deal with skirmishes in their realm handle the situation in different ways, said Davis.

In some situations, one physician interprets the whole study and bills for the professional component.

In other situations, the radiologist interprets the entire study and bills for the professional component, but pays fair market value to a cardiologist to provide an “over-read” of the heart portion for quality improvement (QI) purposes.

Under other circumstances, the cardiologist interprets the entire study and bills for the professional component, but pays fair market value to a radiologist to provide an over-read of the nonheart portion for QI purposes.

From a regulatory and compliance standpoint, Davis dissuades physicians and administrators from filing claims with bills for incomplete procedures.

“All these alternatives are dicey from a regulatory standpoint,” he said. “But the devil is in the details as to how to actually make this work.”

Other tips he offered include the following:

  • If the study is interpreted by one physician, determine a quality-driven, clinically appropriate method for dividing the imaging studies among the cardiologists and radiologists.

  • If a false interpretation causes a negative patient outcome, be wary of patient inquiries and potential lawsuits. Under such circumstances, expect patients to ask why their studies weren’t interpreted by the other physician (e.g., why didn’t the cardiologist read the scan, or why didn’t the radiologist perform an interpretation?).

    In any event, said Davis, administrators should ensure that any agreement has statistically, quality-driven, medically necessary requirements in place. This protects the patient, physician, and practice, he said.

    Ending hospital conflicts

    At the risk of creating tension with cardiologists, some hospitals have stepped in to make sure that cardiologists don’t practice beyond their current qualifications.

    Some options include the following:

  • The hospital allows cardiologists to perform the interpretations for their own patients just as they would for a coronary angiogram using catheterization

  • The hospital engages the radiologists to perform a QI over-read

  • The cardiologists bill for the interpretation and retain all of the professional compensation

  • The hospital pays fair market value compensation to the radiologists for the over-read

    “The hospital feels justified to ensure quality or just rational expectation on who reads what. It’s surprising how many hospitals have actually jumped in to help radiologists,” Davis said.

    Clarifying the conflict

    Even when cardiologists and radiologists extend their hands for a proverbial goodwill handshake, the conflict may not be resolved.

    Those who govern the world of reimbursement have rules of their own that must be followed under pain of financial burdens or worse, said Davis.

    Medicare generally doesn’t accommodate the idea of two physicians sharing the interpretation, he said.

    Essentially, when a physician submits a bill to Medicare, that person is claiming that he or she completed a specific procedure, Davis explained.

    Under shared-reading agreements, however, neither physician completely rendered the service. Reporting as if they had completed the service would then earn CMS’ ire.

    “This is a complicated coding problem,” said Davis. “The code itself implies complete reads of certain images. If an agreement for over-reads or split reads exists, then there is also a risk of filing a false claim.”

    To avoid this pending pitfall (while still extending that hand for the shake), query whether the billing physician legally submitted a bill.

    “From my standpoint, whoever is the billing agent should take the nonofficial portion of the reading and make it a part of their own dictated report. Your workflow processes will be vital here.”

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