Experience. Integrity. Advocacy.
Experience. Integrity. Advocacy.

Secondary Imaging Interpretation and the Use of Substitute Physicians


The Centers for Medicare and Medicaid Services (CMS) took the opportunity during the rule making with comment period for the 2015 Physician Fee Schedule to seek comment on two issues they may eventually address in future rule making, namely secondary interpretation of images and substitute physician billing arrangements.

For image interpretation, Medicare generally makes only one payment for the professional (or interpretive) component of an image service. Occasionally, under ‘‘unusual circumstances,’’ physicians bill for secondary interpretations using modifier -77. Those unusual circumstances include emergency room physicians providing an immediate interpretation or identifying a questionable finding and subsequently requesting a second interpretation from a radiologist. In all cases, the ‘‘professional component’’ interpretation service should be billed only when a full interpretation and report is made, not just for a ‘‘review,’’ which is paid for as part of an E/M payment.

Because recent technological advances have greatly improved access to existing diagnostic-quality radiology images, physicians are increasingly accessing and utilizing these images to inform the diagnosis and are recording an interpretation in the medical record to avoid ordering duplicative tests. Should Medicare pay for these secondary interpretations?

This and other questions were posed to the healthcare community for comment as part of the 2015 Fee Schedule Final Rule. According to CMS, they were interested in comments related to the following: “the circumstances under which physicians are currently conducting secondary interpretations and whether they are seeking payment for these interpretations; whether more routine payment for secondary interpretations should be restricted to certain high-cost advanced diagnostic imaging services; considerations for valuing secondary interpretation services; the settings in which secondary interpretations chiefly occur; and considerations for operationalizing more routine payment of secondary interpretations in a manner that would minimize burden on providers and others.”

CMS also sought comment on substitute physician billing arrangement. Current law seems to allow for two types of substitute physician billing arrangements: (1) An informal reciprocal arrangement where doctor A substitutes for doctor B on an occasional basis and doctor B substitutes for doctor A on an occasional basis; and (2) an arrangement where the services of the substitute physician are paid for on a per diem basis or according to the amount of time worked. Substitute physicians in the second type of arrangement are sometimes referred to as ‘‘locum tenens’’ physicians.

CMS is concerned about the operational and program integrity issues that result from the use of substitute physicians to fill staffing needs or to replace a physician who has permanently left a medical group or employer, particularly as it relates to enrollment with Medicare or updates of enrollment records when physicians change or leave practices and the inability of Medicare to ensure proper credentialing of substitute physicians in those cases. CMS solicited comments regarding how to achieve transparency in the context of substitute physician billing arrangements for the identity of the individual actually furnishing the service to a beneficiary. Also, through the comments, they hoped to better understand current industry practices for the use of substitute physicians and the impact that policy changes limiting the use of substitute physicians might have on beneficiary access to physician services.

Both issues are currently under consideration for future rulemaking based on the comments received and the information gathered.

For more information, review sections II.K. and III.H. of the 2015 Medicare Physician Fee Schedule Final Rule with Comment Period.

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Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

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