Comparison of Radiologists and Other Specialists in the Performance of Lumbar Puncture Procedures Over Time.

BACKGROUND AND PURPOSE: Lumbar punctures may be performed by many different types of health care providers. We evaluated the percentages of lumbar punctures performed by radiologists-versus-nonradiologist providers, including changes with time and discrepancies between specialties. MATERIALS AND METHODS: Lumbar puncture procedure claims were identified in a 5% sample of Medicare beneficiaries from 2004 to 2017 and classified by provider specialty, site of service, day of week, and patient complexity. Compound annual growth rates for 2004 versus 2017 were calculated; t test and χ2 statistical analyses were performed. RESULTS: Lumbar puncture use increased from 163.3 to 203.4 procedures per 100,000 Medicare beneficiaries from 2004 to 2017 (overall rate, 190.3). Concurrently, the percentage of lumbar punctures performed by radiologists increased from 37.1% to 54.0%, while proportions performed by other major physician specialty groups either declined (eg, neurologists from 23.5% to 10.0%) or were largely unchanged. While radiologists saw the largest absolute increase in the percentage of procedures, the largest relative increase occurred for nonphysician providers (4.2% in 2004 to 7.5% in 2017; +78.6%). In 2017, radiologists performed most procedures on weekdays (56.2%) and a plurality on weekends (38.2%). Comorbidity was slightly higher in patients undergoing lumbar puncture by radiologists (P < .001). CONCLUSIONS: Radiologists now perform most lumbar puncture procedures for Medicare beneficiaries in both the inpatient and outpatient settings. The continuing shift in lumbar puncture responsibility from other specialists to radiologists has implications for clinical workflows, cost, radiation exposure, and postgraduate training.

Evolving Use of fMRI in Medicare Beneficiaries.

Using the Medicare Physician-Supplier Procedure Summary Master File, we evaluated the evolving use of fMRI in Medicare fee-for-service beneficiaries from 2007 through 2017. Annual use rates (per 1,000,000 enrollees) increased from 17.7 to 32.8 through 2014 and have remained static since. Radiologists have remained the dominant specialty group from 2007 to 2017 (86.4% and 88.6% of all services, respectively), and the outpatient setting has remained the dominant place of service (65.4% and 65.4%, respectively).

Medicare for All: Considerations for Neuroradiologists.

The year 2019 featured extensive debates on transforming the United States multipayer health care system into a single-payer system. At a time when reimbursement structures are in flux and potential changes in government may affect health care, it is important for neuroradiologists to remain informed on how emerging policies may impact their practices. The purpose of this article is to examine potential ramifications for neuroradiologist reimbursement with the Medicare for All legislative proposals. An institution-specific analysis is presented to illustrate general Medicare for All principles in discussing issues applicable to practices nationwide.

Board Certification Characteristics of Practicing Neuroradiologists.

BACKGROUND AND PURPOSE: Insight into the status of neuroradiology subspecialty certification across the United States could help to understand neuroradiologists' perceived value of subspecialty certification as well as guide efforts to optimize pathways for broader voluntary certification participation. Our aim was to assess board certification characteristics of practicing US neuroradiologists. MATERIALS AND METHODS: The American Board of Radiology public search engine was used to link Medicare-participating radiologists with American Board of Radiology diplomates. Among linked diplomates, 4670 neuroradiologists were identified on the basis of 3 criteria: current or prior neuroradiology subspecialty certification or currently >50% clinical work effort in neuroradiology based on work relative value unit-weighted national Medicare claims ("majority-practice neuroradiologists"). Subspecialty certification status was studied in each group, using Centers for Medicare & Medicaid Services data to identify additional physician characteristics. RESULTS: Of 3769 included radiologists ever subspecialty certified, 84.1% are currently subspecialty certified. Of 1777/3769 radiologists ever subspecialty-certified and with lifetime primary certificates (ie, nonmandated Maintenance of Certification), only 66.6% are currently subspecialty certified. Of 3341 included majority-practice neuroradiologists, 73.0% were ever subspecialty certified; of these, 89.1% are currently subspecialty certified. Of 3341 majority-practice neuroradiologists, the fraction currently subspecialty certified was higher for those in academic (81.3%) versus nonacademic (58.2%) practices, larger versus smaller practices (72.1% for those in ≥100 versus 36.1% for <10-member practices), US regions other than the West (64.1%-70.6% versus 56.5%), fewer years in practice (77.5% for 11-20 years versus 31.3% for >50 years), and time-limited (73.5%) versus lifetime (54.9%) primary certificates. CONCLUSIONS: More than one-quarter of majority-practice neuroradiologists never obtained neuroradiology subspecialty certification. Even when initially obtained, that certification is commonly not maintained, particularly by lifetime primary certificate diplomates and those in nonacademic and smaller practices. Further investigation is warranted to better understand neuroradiologists' decisions regarding attaining and maintaining subspecialty certification.

Characteristics of MR Neuroimaging Services Billed by Radiologists versus Nonradiologists.

BACKGROUND AND PURPOSE: Although most neuroimaging examinations are interpreted by radiologists, many nonradiologists provide interpretation services. We studied day of the week, site of service, and patient complexity differences for common Medicare MR neuroimaging examinations interpreted by radiologists versus nonradiologists. MATERIALS AND METHODS: Using carrier claims files for a 5% sample of Medicare beneficiaries from 2012 to 2014, we identified all claims for brain and lumbar spine MR imaging examinations. Services were categorized by physician specialty, day of the week, and the site of service. Patient complexity was calculated using Charlson Comorbidity Indices. The χ2 was performed to test statistical significance. RESULTS: A provider specialty could be identified for 568,423 brain and lumbar spine MR imaging examinations. Of weekday examinations, radiologists interpreted 475,288 (92.3%), and nonradiologists, 39,510 (7.7%). Of weekend examinations, radiologists interpreted 52,028 (97.0%) and nonradiologists 1597 (3.0%). Radiologists interpreted 145,904 (98.7%) examinations in the inpatient hospital and emergency department settings versus 1882 (1.3%) by nonradiologists. Of all examinations, 44,547 of those interpreted by radiologists (8.4%) were on the most clinically complex patients versus 2139 (5.2%) for nonradiologists. All interspecialty differences for day of the week, the site of service, and patient complexity were statistically significant (P < .001). CONCLUSIONS: Although radiologists interpret most common MR neuroimaging examinations for Medicare beneficiaries, in contrast to nonradiologists, they disproportionately render those services on weekends, in higher acuity sites, and on more complex patients. To optimize access and minimize disparities in necessary neuroimaging, quality metrics should consider such service characteristics.

Same-Day Sinus and Brain CT Imaging in the Medicare Population: Are Practice Patterns Changing in Association with Medicare Policy Initiatives?

BACKGROUND AND PURPOSE: Monitoring the frequency of same-day sinus and brain CT (Outpatient Measure 14, "OP-14") is part of a recent large Centers for Medicare and Medicaid Services hospital outpatient quality initiative to improve imaging efficiency. This study investigates patient-level claims data in the Medicare population focusing on where same-day sinus and brain CT imaging is performed and how the frequency of same-day studies changed with time before and during OP-14 measure program implementation. MATERIALS AND METHODS: Research Identifiable Files were used to identify all sinus and brain CT examinations from 2004 through 2012 for a 5% random patient sample of Medicare fee-for-service beneficiaries. Overall and site of service use rates were calculated for same- and non-same-day examinations. Changes were mapped to policy initiative timetables. RESULTS: The number of same-day sinus and brain CT studies from 2004 to 2012 increased 67% from 1.85 (95% CI, 1.78-1.91) per 1000 Medicare beneficiaries in 2004 to 3.08 (95% CI, 3.00-3.15) in 2012. The biggest driver of increased same-day studies was the emergency department setting, from 0.56 (95% CI, 0.53-0.60) per 1000 to 1.78 (95% CI, 1.72-1.84; +215.7%). Overall use of brain CT from 146.0 (95% CI, 145.1-146.9) per 1000 to 176.3 (95% CI, 175.4-177.2; +21%) and sinus CT from 12.6 (95% CI, 12.4-12.8) per 1000 to 15.4 (95% CI, 15.2-15.6; +22%) increased until 2009 and remained stable through 2012. CONCLUSIONS: Previously increasing same-day sinus and brain CT in Medicare beneficiaries plateaued in 2009, coinciding with the implementation of targeted measures by the Centers for Medicare and Medicaid Services. Same-day imaging continues to increase in the emergency department setting.

Upper gastrointestinal hemorrhage and transcatheter embolotherapy: clinical and technical factors impacting success and survival.

PURPOSE: To identify clinical and technical factors influencing the outcome of transcatheter embolotherapy for nonvariceal upper gastrointestinal (GI) hemorrhage and to quantify the impact of successful intervention on patient survival. MATERIALS AND METHODS: A retrospective review was performed of all patients (n = 163) who underwent arterial embolization for acute upper GI hemorrhage at a university hospital over an 11.5-year period. Clinical success was defined as target area devascularization that resulted in the clinical cessation of bleeding and stabilization of hemoglobin level. The clinical condition of each patient at intervention was defined by history, laboratory examination, and two composite indicator variables. With use of logistic regression, the dependent variable, clinical success, was modeled on two categories of clinical and technical variables. A final model regressed patient survival on clinical success and other clinical variables. RESULTS: None of the procedural variables analyzed had a significant influence on clinical success. Several clinical variables did impact clinical success, including multiorgan system failure (OR, 0.36; P =.030), coagulopathy (OR, 0.36; P =.026), and bleeding subsequent to trauma (OR, 7.1; P =.040) or invasive procedures (OR, 6.5; P =.009). Regardless of their clinical condition at intervention, patients who underwent clinically successful embolization were 13.3 times more likely to survive than those who had an unsuccessful procedure (CI, 4.54-39.2; P =.000). Nevertheless, patients with multiorgan system failure were 17.5 times more likely to die, independent of the outcome of the procedure (CI, 0.014-0.229; P =.000). CONCLUSION: Arresting nonvariceal upper GI hemorrhage with transcatheter embolotherapy has a large positive effect on patient survival, independent of clinical condition or demonstrable extravasation at intervention. Aggressive treatment with transcatheter embolotherapy is advisable in patients with acute nonvariceal upper GI hemorrhage.

CPT coding by interventional radiologists: accuracy and implications.

PURPOSE: To evaluate the accuracy of Current Procedural Terminology (CPT) coding for interventional radiology services when coding is performed by the operating physician. MATERIALS AND METHODS: Coding data for 1,174 interventional radiology encounters in 736 patients were analyzed for appropriate use of CPT codes. Physician operators initially assigned provisional codes. Formal coding for billing purposes was performed at a later date by one of two experienced interventional radiology physician coders. Initial operator coding errors and associated relative value unit (RVU) impact were analyzed. The coding patterns of experienced physician coders were compared with those of the other interventionalists. RESULTS: Only 82% of encounters were initially coded correctly, with a small net tendency toward undercoding. The overall net RVU impact of errors was only -1.2%, with the effects of undercoding outweighing those of overcoding. More complex cases (> or =4 CPT codes) were much more likely to be coded erroneously than less complex cases (24% vs 14%, P <.001). Experienced physician coders committed significantly fewer errors than other physicians (10% vs 25%, P <.001), but there was a similar minimal net RVU impact of errors (-1.1% vs -1.4%, P =.198). CONCLUSION: Although initial physician coding errors for interventional radiology procedures are common, the net RVU impact is minimal. The accuracy of experienced physician coders is significantly higher than that for other interventionalists. Because of the regulatory consequences of coding inaccuracies, practices should establish quality improvement systems to minimize errors and use the skills of experienced individuals in their coding processes.

Coexpression of cytokeratins 7 and 20 confirms urothelial carcinoma presenting as an intrarenal tumor.

BACKGROUND: The differentiation of epithelial tumors arising in the kidney (urothelial vs. renal cell carcinoma) sometimes can be difficult by clinical and radiologic studies. Because urothelial and renal epithelium express unique cytokeratin (CK) 7 and 20 profiles, the authors studied the utility of these markers to confirm the diagnosis of urothelial carcinomas that present clinically as kidney masses. METHODS: Using commercially available monoclonal antibodies, paraffin section immunohistochemistry was used to examine two recent cases of urothelial carcinomas presenting as renal tumors. Tissues were stained for CK7 and CK20 and the expression compared between the tumor and benign tissue. RESULTS: Both cases showed solid renal masses that clinically and radiographically could have been of renal cell origin, but subsequently were confirmed histologically to be extensive renal involvement by urothelial carcinoma. The tumors coexpressed both CK7 and CK20, which is the expected profile for carcinomas of urothelial but not renal origin. CONCLUSIONS: The results of the current study show that coexpression of CK7 and CK20 is a useful diagnostic aid in the differential diagnosis of epithelial kidney tumors of urothelial cell versus renal cell origin.

Dialysis graft declotting with very low dose urokinase: is it feasible to use "less and wait?".

PURPOSE: "Lyse and wait" dialysis graft declotting is simple and effective, but the minimum necessary dose of urokinase is unknown. The efficacy of the technique with very low dose urokinase is evaluated. MATERIALS AND METHODS: Twenty-one grafts in 17 patients were declotted with use of the lyse and wait technique, but with 5,000-15,000 U of urokinase initially. Graft angiography was performed when an interventional suite was available. Declotting was completed in the manner chosen by the individual operator. Angiograms, interventional radiology records, and dialysis records were reviewed. RESULTS: Technical and clinical success were achieved in 95% of cases. Mean initial urokinase dose was 6,667 U. Initial angiography was performed at a mean 86 minutes. Two cases required second 5,000-U boluses to achieve complete graft thrombolysis. In all other cases, complete or near complete graft thrombolysis was observed with the initial very low dose. No bleeding, arterial embolic, or pulmonary embolic complications were observed. CONCLUSIONS: Doses of urokinase as low as 5,000 U are effective for lyse and wait declotting. A substantial reduction in drug costs can be expected with the "less and wait" modification. Bleeding risk may also be reduced.