AAOS Bulletin - June, 2006

Taking a closer look at office-based imaging

Rapid growth in the volume of imaging services over the past few years has prompted some national radiology groups to point fingers at nonradiologists for excessive and inappropriate utilization. They’ve used this argument to fuel efforts to limit—and preferably prohibit—nonradiologists, including orthopaedists, from providing in-office imaging services. Although these groups are concerned about all imaging modalities, they focus on high-end imaging services, such as MRIs and computed tomography scans (CTs).

Arguments: pro and con

The volume of imaging services has increased dramatically since the late 1990s. In a June 2005 report to Congress, Medicare Payment Advisory Commission (MedPAC) found that the number of imaging services performed on Medicare patients between 1999 and 2003 grew twice as fast as all other physician services.

Some radiologists argue that this growth is primarily because of nonradiologists. Yet between 2003–2004, the greatest increase in Medicare spending on imaging services went to radiologists.2 According to the Centers for Medicare and Medicaid Services (CMS), radiologists, as a whole, were paid 35 percent more for imaging services in 2004 than in 2003, while imaging service payments to orthopaedists increased by only 2 percent.3

Another argument is that many nonradiologists perform inappropriate or unnecessary imaging services. However, there is no conclusive evidence to back this argument. On the contrary, as innovations in technology make office-based imaging more feasible, the need for more costly and more invasive diagnostic procedures decreases.

Patient care considerations

It’s usually much more convenient for a patient to get an MRI in an orthopaedist’s office shortly after seeing the doctor than for the patient to go elsewhere to obtain the image. This is especially true in rural and other underserved areas with few, if any, imaging centers.

“It’s a matter of access,” Dr. Shapiro points out. “It’s the ability to see a patient and make a diagnosis within a matter of hours instead of days or weeks.”

BOC member Kurt F. Konkel, MD, who is part of a multispecialty group in Milwaukee, Wis., agrees. “We have a lot of older patients whose families take off work to bring them in. The ability to get everything done at one place, at one time, is important to them,” he says.

Because most orthopaedic practices with MRIs use the same kind of well-trained technicians to operate their equipment as imaging centers owned by radiologists and hospitals, the issue becomes a “matter of interpretation”—the interpretation of images.

Only 2 percent of orthopaedists who have MRIs in their offices interpret the images without a radiologist, according to a 2004 AAOS member survey.4 Although orthopaedists never make a treatment decision without looking at the images first, the vast majority of orthopaedists with MRIs send the images to radiologists for interpretation. Therefore, at least in orthopaedics, radiologists are closely involved in almost all MRI services.

Federal legislation

Under the Stark antiself-referral laws, physicians cannot refer their patients to entities, including imaging centers, in which they have an ownership interest. However, physicians who have imaging equipment in their offices don’t fall under this restriction.

A move is under way to eliminate this in-office ancillary service exception. To counter those efforts, physicians have taken two important steps.

At its annual meetings in 2004 and 2005, the American Medical Association’s (AMA) House of Delegates voted to oppose any attempts to prevent nonradiologists from providing diagnostic imaging services. AMA delegates took this position in response to lobbying efforts by the AAOS and several other national specialty societies. Their decision shows that the overwhelming majority of physicians in most specialties oppose efforts to limit physician use of imaging equipment in their offices.

A second important step was the formation of the Coalition for Patient-Centered Imaging by the AAOS and 22 other physician and medical organizations. The coalition’s efforts include meetings with more than 50 congressional offices, testifying before the House Ways and Means Health Subcommittee, holding a briefing for congressional staff and members of the press and issuing numerous press statements. These efforts have effectively prevented any changes to the Stark laws.

In March 2005, MedPAC recommended that Congress give CMS the authority to create an imaging accreditation program. Standards would cover imaging equipment, the qualifications of technicians, the qualifications and responsibilities of supervising physicians and the technical quality of the images produced, among other factors. MedPAC also suggested that Congress authorize CMS to work with existing accreditation programs, such as the Intersocietal Commission for the Accreditation of Magnetic Resonance Laboratories (ICAMRL), which the AAOS sponsors.5

To date, Congress has not acted on these recommendations, and with midterm elections approaching, action on the federal level seems unlikely. The same cannot be said, however, of the state and local levels.

Closer to home

As a result of efforts by some national radiology groups, Connecticut and Rhode Island passed legislation requiring physicians to be accredited by the American College of Radiology (ACR) before the physicians can provide and/or get paid for MRI services. Unfortunately, it’s difficult for nonradiologists to get ACR accreditation. Practices with extremity MRIs cannot receive ACR accreditation under any circumstances.

During the most recent legislative session, bills to require accreditation were introduced in California, Indiana, Massachusetts, Minnesota, Missouri, Tennessee and Washington. Although none of these bills passed, they and similar measures will undoubtedly continue to be introduced.

In other states, radiology interests are bypassing legislation and pursuing opinions from state attorneys general. In 2004, the Maryland attorney general issued an opinion that nonradiologists could not use MRIs and CTs in their offices under Maryland’s antiself-referral law. Although the state attorney general’s opinion does not carry the weight of law, it can be used by parties in a lawsuit. More important, the opinion has a “chilling effect” on physicians using MRIs or CTs in their offices or those who are thinking of leasing or purchasing them.

Accreditation is now required by some commercial health plans; others may make it a requirement. Several of these plans only accept ACR accreditation.

The AAOS response

State orthopaedic societies are taking the lead in dealing with this issue on the state level. They have opposed these bills at every step of the way. The AAOS is contributing both financially and with other resources.

In addition, the AAOS and several other concerned specialty societies have established ICAMRL, with an accreditation program geared toward nonradiologists and including extremity MRIs. MedPAC has already recognized the ICAMRL as a viable accreditation program for future Medicare use.

With the ICAMRL as an alternative, the Rhode Island Orthopaedic Society convinced state legislators to amend the MRI accreditation law and allow for accreditation bodies other than the ACR. ICAMRL officials are now trying to persuade commercial health plans interested in MRI accreditation to do the same.

For orthopaedists who have in-office MRIs, ICAMRL accreditation may offer protection if either their state legislature or health plans begin requiring accreditation.

On another front, the Coalition for Patient-Centered Imaging is focusing on private health plans that seek to limit or prohibit nonradiologists from providing imaging services. The coalition has written several of these health plans and is planning meetings between their executives, coalition leaders and local physicians in the near future.

Meanwhile, orthopaedists should be alert for health plans that may be changing their policies on imaging services. If something develops, please contact the AAOS department of socioeconomic and state society affairs.


The attack on ancillary services is one more chapter in the struggle to maintain quality orthopaedic care. Although economics may be behind the attacks, the best way to deal with these challenges is to fight for what’s best for patients.

Robert C. Fine, JD, CAE, is director of the AAOS department of socioeconomic and state society affairs. He can be reached at fine@aaos.org


1. MedPAC Comment Letter to the Congress Re: Its Study on the Feasibility of Medicare Beneficiaries’ Having Direct Access to Physical Therapists, December 2004.

2. A Data Book: Medicare Spending and the Medicare Program. MedPAC, June 2005.

3. Letter from the Director of the Center for Medicare Management, CMS, to the Chair of the MedPAC, March 31, 2005.

4. MRI Survey 2004 –Final Report, American Academy of Orthopaedic Surgeons, December 23, 2004.

5. Statement of Mark E. Miller, PhD, Executive Director, Medicare Payment Advisory Commission Before the Subcommittee on Health, Committee on Ways and Means, U.S. House of Representatives, March 17, 2005.

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