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Advanced Imaging Protocols and Medical Billing


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Residents, fellows, and radiology assistants in our institution oversee the imaging requests and protocol the CT and MRI studies in order to ensure optimal patient care, appropriate use of resources, and to comply with Joint Commission requirements. The Joint Commission asks that radiology practices verify advanced imaging study appropriateness prior to the acquisition of images. We protocol roughly 500 CT and MRI studies per day, excluding the non-contrast enhanced head, neck, and facial bones CT studies, which are delegated to the technologists. At the affiliated Veterans Health Administration (VA) medical center, attendings and residents are in charge of the protocols. In private practices, CT or MR technologists and radiologists are.

Technologists often perform well in quality assurance, hence basic radiographs seldom require repeat/extra views, and ultrasound studies are checked in real-time by a radiologist if needed, However, advanced imaging requires more radiologist involvement in quality control to confirm: 1) inclusion of appropriate anatomy 2) timing and volume of contrast 3) organ-specific protocols and 4) appropriate use of sequences, particularly with MRI. Recall of patients that have inadequate or wrong imaging imposes a cost on the patient and the health system. Therefore, reducing recall to zero is our objective.

Appropriate exam protocoling to meet JC requirements comprises of the following approximate steps:
1. The first step is to find the actual indication. “Evaluate kidney lesion” can mean a number of things: following up on known angiomyolipoma, characterizing an incidental mass seen on last cuts of chest CT, or evaluating nephrectomy bed for renal cell carcinoma recurrence, for example. In these cases, non-contrast enhanced abdomen CT, multiphasic abdomen CT (or even abdomen MRI) and CT abdomen and pelvis with IV contrast are considered appropriate scans, respectively. Study indications are often a generic expression from the EPIC drop-down menu such as “Abd pain, R/O Appy,” “abnormality in kidney area,” “CP or SOB, mod pretest probability,” and, sadly, I have had instances of “100 percent,” “post-op,” or “NA” as the study indication. Occasionally, there is a chief complaint plus relevant piece of history or physical exam. It falls to us, as radiologists, to hunt for the complaints, symptoms, lab values or any relevant piece of information in the EHR. Studies may be canceled, delayed or replaced by other modalities after our input to the ordering providers. Digging through medical records and reaching clinicians can be very time-consuming — sometimes the information that can be derived simply from prior available imaging can answer the question.
2. The next step is to adjust the anatomy and pick the right protocol. This is somewhat different across practices and depends on the departments’ policies and protocols. It is not uncommon to decrease or expand the scan length, use multiphasic organ-specific protocols or perform double studies while needed. The goal is to answer the question with the least radiation and risk to the patient!
3. Much like other institutions, our health system faces challenges around the appropriate use of contrast. There remains much concern (probably unfounded, according to many recent publications) about contrast nephrotoxicity. And disagreements about the use of oral contrast are, if anything, even greater. In the ED setting, oral contrast is often seen as a needless delay in patient work-up. We have a standardized requirement for oral contrast in some situations, with considerable latitude afforded to the radiologists and ED physicians around individual patients. We also have a guideline that seeks to avoid two contrast administrations within 24 hours, unless medical necessity is documented by the care team. Before opening the contrast discussion, we always check the eGFR and history of contrast allergy.
4. Pregnancy is another critical input in our protocol process. Every female patient aged between 10 and 60 years old should either be tested or counseled and asked to sign a waiver. Patients who have had hysterectomies are excluded.
5. For some studies we ask the technologist to notify the radiologist after acquiring the non-contrast and before giving the IV contrast or ending the scan. Examples include trauma cases, adrenal studies, and pediatric scans.
6. All of these factors require us to be in contact with the technologist and receive and offer suggestions for modifications, with final decisions included in the EHR system.

Currently this process is considered a pre-procedural task in terms of RVU and reimbursement, and not an extra service. According to Medicare, consultation is described as “a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source.” Along the same line, expert advice on 500 studies a day reinforced by knowledge and a decent amount of time and effort is a consult service (it is ironic that we often find more clinical questions, too).




By Sarvenaz Pourjabbar, MD, diagnostic radiology resident at Yale University-New Haven Hospital, and Howard Forman, MD, FACR, professor of diagnostic radiology at Yale University.

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