Healthcare Fraud Shield’s Latest Article: Are You Over X-rayed?

25 Feb

Ever think about all of the things you do that expose you to radiation?   Depending on where you live just based on altitude alone you are exposed to more radiation.  Radiation also comes from minerals in the ground, Radon in your home, flying on a plane, and more.  What about the different medical tests and procedures you undergo?  Did you ever wonder just how much radiation you are subject to throughout a year?  According to the National Council on Radiation Protection and Measurements (NCRP), the average annual radiation dose per person in the United States (U.S.) is  6.2 millisieverts (mSv) or 620 millirem (rem).The sievert is the international unit and the rem is the U.S. unit.

As an example, CPT (Current Procedural Terminology) code 72125 is a Computed tomography (CT) of the cervical spine has an average effective dose of radiation of 6 mSv, a mammogram on average is .4 mSv and a CT angiogram is on average 16 mSv. 2    So how much is too much?  Research shows there starts to be a risk for cancer starting at about 100 mSv per year.  A dose of 10,000 mSv would be fatal, about 5,000 mSv would be lethal in about 50% of those exposed.

Why is this important?

While many of us are tasked with ensuring claims are paid properly and safeguarding against potential Fraud, Waste and Abuse (FWA), we also want to ensure that healthcare provides consider the best interest of the patients.  What if patients are receiving an excessive amount of radiation based on the various tests being performed?  Are these tests medically necessary? 

What to look for?

  1. Providers excessively billing a higher volume of radiological tests per patient than others. You would need to incorporate in your analytics the mSv calculation per tests. 
  2. A scenario in which members may be exposed to excessive radiologic testing is in the emergency room. “ER shoppers” (who frequent various ER’s to possibly seek narcotics) may have the same studies performed from ER to ER. This is frequently seen with ER shoppers complaining of abdominal pain. To rule out serious conditions, this symptom could warrant a CT of the abdomen.
  3. Compare and analyze the diagnoses and patients’ medical history for supported services.
  4. Monitor patients who are exceeding the threshold of acceptable levels of radiation. You may want to refer these members to Medical Management or Quality Assurance.

If you have any questions or comments, please reach out to SIU@hcfraudshield.com.

  1. https://www.epa.gov/radiation/radiation-sources-and-doses
  2. https://www.health.harvard.edu/cancer/radiation-risk-from-medical-imaging
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