Comments on: Is a Radiologist Required Under Medicaid?

Question: Is a Radiologist Required Under Medicaid?

whitebird — Wed, 02 Aug 2006 09:37:12 -0800

Is a radiologist required to be in the office during an MRI, according to Medicaid regulations?

According to the Medicare National Coverage Determinations Manual, in a hospital setting for a CT scan, you need a "radiologist or other qualified physician...in charge of the procedure," while for a non-hospital health care facility, "the diagnostic procedure must be performed by or under the direct personal supervision of a radiologist or other qualified physician." Do the same rules apply to MRI? Bonus points given for a link to specific Medicaid/Medicare regulations applicable.

By: sarahnade

sarahnade — Wed, 02 Aug 2006 10:59:22 -0800

whitebird, I'm interested in this question as well. Unfortunately, I don't have an answer for you re: Medicaid, but I have a bit of an idea how it is done in practice.

I have been thinking about becoming an X-Ray Tech (an Associate's degree), but the class descriptions I've read online don't mention anything about CTs or MRIs. So I asked a coworker, who's father is a general practitioner, and he said that the people who run CTs and MRIs are X-ray techs, with an additional certifcate in that area. It didn't sound like, to me, they needed a doctor there while they were doing the scanning. Perhaps one requires a doctor to read and interpret the scan (which is how it's done in hospitals-- the tech runs the scanner and the radiologist interprets it and then dictates a report).

Similarly, I've looked at a few CT/MRI tech job descriptions on the website of the hospital I work at, and none of them mention supervision by a doctor at all. In fact, one description for an MRI Tech specifically states:

"Through the use of independent judgement and initiative, is able to perform MRI imaging sequences necessary to reach a medical diagnosis and decision... Must have the ability to work independently and be self motivated." That doesn't sound like a doctor is there while the scanning is happening.

I believe that one could interpret "in charge of" and "under direct personal supervision" to mean that the tech's direct supervisor is a doctor, and that person is continually checking on the quality of the tech's work, which would be true, if that doctor was interpreting all the scans. He/She would be aware if the quality of the images was not good, or the scan wasn't done properly. Also, in order for a patient to even get an MRI or CT, a doctor has to write an order, which the tech then has to follow according to their training and regulations.

Hope this was a little helpful...

By: FortyT-wo

FortyT-wo — Wed, 02 Aug 2006 11:19:44 -0800

I work in a hospital in radiology, and there are definitely no radiologists present for CTs or MRIs. These are performed by Radiograpic Techs, no doctors or nurses are required to be present (though a nurse might come if the patient's health requries it, there's not one stationed in the scanning areas) ...is it possible there's a confusion between Radiographers and Radiologists?

Some "for instances"... Our CT department is open 24/7. Between 9pm and 6am we have no in-house radiologist at all (they read from home or use a nighthawk service). We have offsite facilities that send their films to our rads to be read. There's no in-house rad there either.

We do have a department for Special Procedures (also called Interventional Radiology) ... This is where radiology is used in some part of a treatment procedure. In this case, a radiologist is present, because he's performing whatever procedure is being done. There are nurses there too, but these are situations like spinal/kidney taps, filter placements, picc line insertion, etc. There's no MRI involved, though sometimes they do use CT for guided biopsies.

It may be like Sarah said... They're "supervising" in that they see the end result. But they're definitely not there when the exam is being performed, barring some very unusual circumstance.

By: Snerd

Snerd — Wed, 02 Aug 2006 11:40:07 -0800

The Centers for Medicare and Medicaid Services (CMS) has requirements for level of supervision for each specific radiology procedure. If you can determine the specific MRI procedure's Current Procedural Terminology (CPT) code, you can look up the procedure's payment information including supervision requirements on the CMS website.

The codes identifying the required level of supervision are:
01 = Procedure must be performed under the general supervision of a physician.
02 = Procedure must be performed under the direct supervision of a physician.
03 = Procedure must be performed under the personal supervision of a physician.
...and there are others, but I couldn't find a good way to link them. You can find them buried within CMS public use files on physician fee schedules.

The 03 level requires the physician be right there in the room with the patient; 02 means a physician is in the building; and 01 doesn't require a physician anywhere at the time.

This is oversimplifying, but my impression is that if the MRI test requires injection of contrast material, a physician will need to be in the facility. In the examples FortyT-wo cites, I think the physicians in the emergency department are considered to cover this requirement.

By: cayla

cayla — Wed, 02 Aug 2006 18:58:45 -0800

My understanding is that Snerd has it right.

Generally speaking, if there is contrast involved a physician (but AFAIK, not necessarily a radiologist) needs to be available in case there is a contrast reaction. Otherwise, I think that the techs work pretty independently from the rads.

Radiology residents can sometimes make a little extra cash moonlighting by hanging out and studying within a couple minutes of the CT scanner to fulfill this supervision if there wouldn't otherwise be any other physician there.

MR can also involve contrast and therefore could fall under this scope.

There are probably other exceptions, but I can't think of any.

[I work in radiology too, but on the informatics side so this is just my impression and not fact.]

By: whitebird

whitebird — Thu, 03 Aug 2006 19:15:04 -0800

Your knowledge has helped a great deal--I would never have been able to come up with this solely with my own research!