Dividing Lines

It has been observed more than occasionally that radiologists have a tendency to hedge.

The rads in question, and I daresay even those who don’t, could quickly tell you why they express uncertainty in their reports. I’m not getting into most of those reasons right now.

One factor which probably wouldn’t make most rads’ “top ten” is the larger world of health care in which radiology is situated. In an awful lot of ways having nothing to do with rendering a diagnosis (or excluding one), we’re surrounded by uncertainty. Some unavoidable, but some just seem, well, kinda unnecessary and dumb.

Take, for instance, the matter of quantifying the imaging cases you’re reading. Should be straightforward, right? You get a CT of the chest, it counts as a CT of the chest. An ultrasound of the abdomen is an abdominal sono.

Except for when it’s not. The tech who scanned that chest, for instance, carried the study down to the iliac crests, so now you’re allowed to add an order for the abdomen (and even if you don’t claim the credit, you’ll still be responsible for anything shown in the images). Or the abdominal sono didn’t include the spleen or left kidney, so now you’d darned well better only report a “limited” abdomen.

If you’re a rad in a nice, salaried position without much emphasis on how many RVUs you’re generating, it might not matter so much to you-might not even be on your radar. You get a case, you read it out as it was ordered…maybe sometimes the billing people ask you to addend your report, but you’re not all that emotionally invested in it.

Otherwise, especially if you’re in a pure “eat what you kill” situation like much of the teleradiology world, this stuff can drive you to distraction. In large part because these rules about what constitutes which kind of study seem rather arbitrary, subject to change, and made up by anybody but a radiologist who actually reads these things for a living.

It flies in the face of common sense. How is it that it “counts” the same if I get an abdominal CT whose upper margin is right at the diaphragmatic level, versus another where the tech carelessly scanned up through the heart…but didn’t quite get the aortic arch so I could justify billing for a chest CT, too? I’m now reporting on more than half of the thorax, with all the extra work and liability that entails. For that matter, why should it count as a chest if it just gets the arch but skips the lung apices?

Sometimes the nonsense rebounds to our favor, such as a pelvic sono with transabdominal and endovaginal technique. Hurrah, I got two studies for the effort of one…even if the “transabdominal” exam consisted of a single image from the sonographer showing me a nondistended bladder with zero diagnostic detail resulting, before the tech reached for the other probe.[[{"type":"media","view_mode":"media_crop","fid":"48814","attributes":{"alt":"Quantifying imaging","class":"media-image media-image-right","id":"media_crop_9723754133300","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"5859","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 170px; width: 170px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"©3Dalia/Shutterstock.com","typeof":"foaf:Image"}}]]

Maybe we can get really granular while we’re at it, and break things down to the organ-specific level-this CT covered the liver, that one covered 1.5 kidneys, etc. Maybe we could go by the volume of tissue; have the scanner calculate the total cubic centimeters imaged.

One wonders why it has to be such a byzantine affair to determine what qualifies for a certain type of study…that is, who benefits from such needless complexity? A cynical mind (like mine, more often than not) might have difficulty coming up with more than one answer: The folks holding the purse strings, who have every reason to invent ways to deny payment for diagnostic services rendered. Sorry, your study only met 18 of our 20 criteria…we’re paying you diddly. Kind of an after-the-fact game of “Mother may I.”

Now, I’m not suggesting that we physicians should have carte blanche to just go ahead and put whatever price tag we think fit upon our hourly labors, or fractions thereof. That privilege is clearly reserved for honest professionals trusted by society to police themselves, like lawyers and accountants.

But maybe, just maybe, it would be okay if a radiologist performing an imaging study had the autonomy to say what kind of study he considered it-chest CT, abdomen sono, upper GI series, whatever. His criteria, not those of some outsider who knows nothing of the clinical situation.

If one worries that some unscrupulous docs might fudge things, routinely doing incomplete studies, it might be a reassurance that their referrers and patients wouldn’t take long to realize that they were getting short shrift, and direct their imaging workups elsewhere.

And if stronger safeguards are needed, there’s always the option of random audits (which, I think, we face anyway). Grab a handful of cases read by the rad during the past few years, and just eyeball them-not a nitpicky “gotcha” hunt for excuses to crucify the doc, but a reasonable, good faith review.