I figured I would jot down some notes on what I have learned about radiology procedures. I am doing this in hopes that others will find it useful and also that some may correct my understanding.
The Payor
To start off with, it helps to understand where the money comes from to pay for radiology procedures. The term "payor" is often used here and can refer to one of many things:
1) Health insurance company (e.g. United Health Group, Wellpoint Inc Group, etc)
2) Health Maintenance Organizations (e.g. Kaiser Permanente, CIGNA, Sharp Health Plan, etc)
3) Private Insurance (companies with self insurance plans)
4) Government (Medicare, Medicaid, VA)
5) The patient (uninsured, HSA)
While the US does not have a single payor like other countries do - Medicare is by far the biggest and tends to set prices across the industry. When medicare decides to cover a new procedure, almost every other payor tends to as well. Likewise, if medicare changes the reimbursement rate for a procedure, the other payors adjust accordingly to.
Ordering the Exam
The origin of imaging procedure begins with the physician that deems it is necessary. In most cases, a physician must justify why they think the procedure is necessary. These justifications are often called "conditions". For example, if your child falls off the monkey bars at school and hurts their wrist, you would take them to a physician and they would suspect the wrist is broken. The doctor would place the order for an xray of the wrist with a condition of "acute wrist trauma". Some payors have electronic systems that can verify that the condition is appropriate for the procedure. For example, ordering an xray of the wrist when the condition is "headache" should be rejected as it is unlikely to help. Likewise, ordering A CT of the wrist for acute wrist trauma condition would be overkill as an XRay would suffice. The ACR has defined a set of appropriateness criteria which can be licensed for use in ordering systems.
Assuming the ordered procedure is found to be appropriate, the next step is to confirm authorization of payment. This step is important because doctors want to get paid and they need to confirm that the payor will in fact pay for it. In some cases, a patient does not have insurance but claim they do. Or perhaps they present the insurance card for an old health insurance company that is no longer covering them. Prior authorization has traditionally been done manually - a person would call or fax the insurance company and wait for a response. This is of course not very efficient - fortunately this is being automated via some recently defined EDI transactions 278. Informatics In Context has a very nice automated prior authorization system, check it out if you are interested.
Scheduling The Exam
Once the exam has been ordered, it needs to be scheduled. This requires many things:
1) Finding a device that can do the procedure. You can't schedule a CT exam on an MRI scanner. Likewise, you cannot schedule a CT brain perfusion procedure on a 4 slice CT scanner.
2) Finding a time slot where the appropriate medical staff are available. Some procedures require staff with specific training - for example, contrast injection must be performed by a physician
3) Finding a time slot long enough for the procedure. Different procedures take different lengths of time.
4) Finding a time slot the patient is available for.
Scheduling is often managed by what is called a RIS or Radiology Information System.
Performing The Exam
Ideally the patient shows up on time, registers at the desk, gets scanned and then goes home. Unfortunately things don't always go as planned - patients show up late, procedures take longer than expected, critical staff are late or don't show up, the equipment breaks or emergency procedures take precedence. The images are generally sent using the DICOM protocol to a PACS or Picture Archival and Communication System.
Reading the Exam
Once the exam has been performed, a radiologist reviews it and issues a report. The report includes their findings (positive and negative). The radiologist typically uses a PACS workstation to read the images. A PACS workstation is usually a Windows based PC with two or more high resolution grayscale monitors. Here is an example of a radiology report.
Billing the Exam
Each radiology procedure is billed in two parts - the technical fee (performing the exam) and the professional fee (reading the exam). Each of these parts has a CPT Code. Payors will reimburse CPT codes at different rates depending upon where the exam was performed and where it was read. For example, an imaging center would typically be reimbursed less than a hospital. Likewise, one imaging center may get reimbursed at a higher rate than another imaging center for the exact same procedure. The reimbursement rate can vary significantly - for example, an imaging center may only be reimbursed $600 for a MRI procedure but a hospital across the street could get reimbursed for $2000 for the sam procedure. If you are paying for imaging out of your own pocket (no insurance or HSA), it is wise to shop around.
In some cases, the billing is split between two organizations. The organization that performs the exam would bill the technical fee and the organization that reads the exam bills the professional fee.
Reviewing the Exam
Once the exam has been read by the radiologist and finalized, it is made available to the ordering physician and possible the patient. The ordering physician is mainly interested in the "impressions" part of the report. This part is a quick summary of what was found and what the radiologist recommends next. Ordering physicians may want to look at the images and/or ask the radiologist a question about the report.
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