Second Opinion:
Is It Worth the Woe?
A Special Thank You to:
Dr. David M. Yousem, M.D., M.B.A. Professor, Department of Radiology Vice
Chairman of Program Development Director of Neuroradiology Johns
Hopkins Hospital
for allowing the use of his material/content in this presentation
Dr. Yousem’s online lecture series can be viewed at:
http://webcast.jhu.edu/mediasite/Catalog/pages/catalog.aspx?catalogId=7e18
b7d5-9c63-487e-aaf1-77a86f83b011
Dr. Yousem’s project was funded through an RSNA Educational Grant
The Breakdown
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Background
Risks vs. Benefits
Starting Out
Potential Pitfalls
Future and Follow-up
Background
• As medical imaging becomes more readily accessible by
innovations such as PACS and teleradiology, there is often the
expectation of the second-opinion consultation by patients and
referring physicians
– Increasing sub-specialization of radiologists may also add to
this as a general community radiologist may not have the
same resources as a trained sub-specialist
• This has several implications for radiologists and their patients
– Though shown to improve patient safety, it has also been
show to affect radiologist productivity
– What are the costs vs. benefits?
Risks vs. Benefits
• Concerns:
– Medicolegal implications
– Lack of reimbursement associated with coding issues
– Productivity effect
– Technique used by outside institutions
• Benefits:
– Patient safety and satisfaction
– Collegial contacts
– Potential for reimbursement
– Already in widespread practice
Concerns: Medicolegal Issues
• Ethical and Legal Responsibilities
– If something was previously missed, what is the correct and
ethical way to report it?
– Retrospective lawsuits?
• Precedent of litigation based on a second opinion exists
in other specialties
» Films are available for several years at the
minimum
» Easy transfer of information
Concerns: Lack of Reimbursement / Coding Issues
•
Very strict requirements for reimbursement2
– Written report
– Documentation of medical necessity
• Even stricter given that payer has already paid once for this service
– Balanced billing requires patient to fill out beneficiary notice form in advance
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Coding dilemmas
– CPT code 76140 (second opinion consultation)
• Originally designed for X-rays only
– Now, “26” modifier after CPT code for original study (“77” for Medicare)
• “Professional fee only”
Concerns: Productivity Effects
• One large study at a tertiary care center demonstrated an 18%
increase in the daily workload3
– 78% of the exams were cross-sectional
– Mean of 18 studies were reinterpreted per day
– Approximately 20% of the workday was spent reviewing these
exams
• Majority of this work is not compensated
• Unmeasured impact
– Delay in interpreting primary studies
– Disturbance of daily workflow (dictations, consultations, etc)
– Educational value to residents/fellows
Superiority-of-Search
• Several previous studies examine the way that radiologists
review images1
– Search (film reviewed de novo and significance evaluated)
vs Nonsearch (findings previously identified and significance
evaluated)
– Search protocols found to be superior
• Nonsearch protocols with higher false positive rates in
large review of CXRs
– Second-opinion consultations often fall under “nonsearch”
• Have previous report available
• Does this affect the associated legal risk?
Concerns: Technique Differences
• Often unsure of exact technique used
– How much contrast?
– How much radiation?
• Is the second opinion consultant also responsible for
radiation safety issues though exam was not at the
primary site?
• Too many or too few - which is worse?
– MR sequences / CT reformations
• Lack of prior exams which may have been available to primary
interpreting physician
Benefits: Patient Safety
• John’s Hopkins neuroradiology department demonstrated
significant discrepancies between original and second-opinion
interpretations4
– 7.6% of studies had differences which affected patient care,
diagnosis, and/or management (1/13 cases)
– Control internal error rate was 1.4%
– For neuroradiology, seemed most often to be head & neck
cases
– Often had overcalled congenital variants
• Rare entities seen less often in private practice vs.
academic
Benefits: Collegial Contact
• Become the “face of radiology”
– Allows face to face or phone contact with several referring
physicians
– Value-added service
• Radiologists as clinicians?
– Interdepartmental discussion allows the medical community to
view radiologists as clinicians not technicians
– Radiologists are often perceived as “obstructionist”
• Allows radiologist to help facilitate accurate and timely patient
care
• Increased physician dependence on imaging interpretation
Benefits: Potential for Reimbursement / Service Already Exists
• Any time a written report is correctly generated there is always
the potential for reimbursement
• Service already exists whether or not departments have an
official policy
• Avoids “curb-side” consultation which may be more costly in
terms of time and medical-legal risk
– disrupts workflow more than studies which are already
DICOM integrated
– verbal consultations may be misquoted in official hospital
records/physician progress notes2
Starting Out
• Departmental/Section physician consensus
• All participants must be on the same page regarding risk/benefit
valuation
• Explain/Offer service to referring clinicians
• Must see as a value-added service
• studies will be in PACS system, no self-interpretation, no
need to interrupt workflow to find a radiologist
• Billing/Coding help
• Previously described strict criteria and low potential for
reimbursement
• IT support to integrate outside images into PACS
• What about images that are not DICOM compatible?
Implementation Tips:
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Try small pilot program in a single section of the department
– Introduces added workload gradually
– Evaluate feedback from department and referring clinicians
Need patient service representatives comfortable with technology
– CDs need to be transferred, images need to be digitized
– Professional attitudes during interaction with patients and referring
doctors daily
– Should be able to provide digitization/upload service 24/7 as goal to
avoid time delays in interpretation (especially if 24/7 film reading is
available)
Billing Coordinator
– Need billers and coders familiar with services provided and
reimbursement rates
Additional Issues:
• Non-DICOM policy
– For example, “we will not interpret images which are not provided in
a PACS compatible format” vs. “outside CDs can be submitted even
if they are unable to be uploaded to PACS”
• Referring physician request slip
– Customized
– Typically include reason for reinterpretation, is outside report
available (yes/no), is delivered CD to be destroyed or returned?
• Patient signature must be acquired before interpretation on beneficiary
notice form
• General policies must be created
– For example, “we will not interpret studies older than 30 days old”
Additional Possibilities:
• Departmental Rounds
– Department of radiology employee makes rounds to clinics
collecting patient provided imaging to be uploaded and
interpreted
• Provide service to private patients not being seen at a
physician’s office
– Patient driven second-opinion search
Acquiring Physician Feedback
• Conducting surveys of referring physicians
– Program is only successful if referring clinicians are satisfied and
recognize value added
• Are reports satisfactory and/or helpful?
• Observe disc submission to report turn-around time
– Has it changed the need for additional pre-operative imaging as
outside images may now be on PACS?
• Constantly adapt and mold the program to meet the needs to referring
clinicians and patients
– Feedback must be acquired at regular intervals (more frequently
during implementation process)
But Is It Really The Best for Us?
• Lack of direct patient contact
– The patient is often not even on-site to make this possible
• Limited patient history
– Interpretation of an image without the pertinent clinical history can
do more damage than good
• Examples include neoplastic diseases that mimic inflammatory
processes or vice versa
• Interpretation limited by quality of study
– May not always have copies of all images that were obtained
(patient disc may only have “pertinent images” - Example,
reformats included but source data not present)
But Is It Really the Best for Us (cont)?
• Radiology practice may become more driven by medicolegal
factors
– Interpretations based on knowledge that images may be
reinterpreted differently
– Potential for legal precedent to be set regarding malpractice
from reinterpretation of studies
• Payment collection issues
– Know which insurers will pay
– What about patients who are expected to self-pay?
Potential Pitfalls
• Disrupts the general workflow / Overextends staff
– An increase of 18% per day may not be feasible
• Large amount of uncompensated time
– Especially pertinent in private practice or productivity
based/RVU type payment schemes
• May require hiring of additional personnel
– Billers, coders, customer service representatives
Future and Follow-Up
• Promise of continued growth in the demand for second-opinion
consultations as radiologist workflows become more streamlined
and PACS makes images readily available to both clinicians and
patients
– There also may be the potential for reimbursement in this
arena which is currently lacking
• Incorporation of an efficient and effective second-opinion
consultation service may improve patient safety and care as well
as the perception of the radiology community by referring
physicians
– The future of radiology is secured by making radiologists
“value-adders”
References
• 1. Swesson, R. “Search and Nonsearch Protocols for
Radiographic Consultation.” Radiology. 1990: 177, 851-56.
• 2. Duszak, R. “Another Unpaid Second Opinion”. Journal of the
American College of Radiology. 2005. 2(9), 793-4
• 3. DiPiro, P., et al. “Volume and Impact of Second-Opinion
Consultations by Radiologists at a Tertiary Care Cancer Center.”
Academic Radiology. 2002; 9: 1430-33.
• 4. Zan, E., Yousem, DM, et al. “Second-opinion Consultations in
Neuroradiology.” Radiology. 2010; 255(1): 135-41.