Concerns over rising imaging costs have led to the consideration by Medicare to limit the ability of clinicians to bill for image interpretation. This move has often been justified as a method to limit self-referral. However, clinicians may not be the only ones capable of referring imaging business to themselves.

This study was conducted to evaluate the frequency and potential cost of self-referral by radiologists found in dictated reports of abdominal computed tomographic (CT) scans for emergency patients.

A retrospective chart review of all abdominal CTs performed at a level 1 academic urban emergency department (ED) with an annual census of 80000 patients for a 12-month period was performed. Two investigators reviewed the medical record dictation on each abdominal CT performed on ED patients older than 18 years, for specific recommendations for additional radiologic testing. To check for agreement, both investigators reviewed approximately 20% of the charts. Recommended additional radiologic tests were recorded, and their costs were estimated by the lowest regional Medicare reimbursements for each test; professional and facilities fees were combined. Statistical methodology included descriptive statistics and interrater agreement.

A total of 785 reports of abdominal CTs were reviewed. Of these reports, 246 (31%) specifically recommended an additional imaging study be obtained for a specific finding. In 38 (5%) cases, 2 separate imaging studies were suggested. The total lowest cost for additional imaging among all of the patients studied was $58157. The mean suggested charge per patient with additional imaging self-referral was $242.32. The additional suggested imaging averaged to $74.09 (95% confidence interval, 63.67-84.50) for each patient receiving an abdominal CT scan in the ED. The largest suggested cost was $1045. Extrapolation to a national level means that more than $226 million of additional costs are seen annually from such CTs. No attempt was made to evaluate the appropriateness of the suggested imaging.

A type of radiology self-referral is possible and can add considerable cost to patient care. In our study, an average of $74 of extra imaging was suggested for each patient who received an abdominal CT. If this holds up nationwide, Medicare can expect at least $226 million worth of radiology self-referrals per year on patients getting abdominal CT.