In order to serve the immediate medical needs of presenting patients, urgent care centers necessarily offer x-ray as a part of their service offerings. X-ray is required to diagnose common urgent care conditions like pneumonia and fractures. Not only does the availability of x-ray services differentiate urgent care centers from other treatment options including walk-in primary care offices and retail health clinics, availability of x-ray is actually a defining feature of urgent care, according to the Urgent Care Association of America’s (UCAOA) certification and accreditation standards.
When an urgent care center performs an x-ray, there are typically two billing components. The technical component includes the services of the radiology technician in the use of equipment and processing images while the professional component identifies services of the radiologist who interprets the film or digital image.
Because the initial image interpretation is generally not by a radiologist, every urgent care that provides x-ray services should have a policy for over-read by a board-certified consulting radiologist. Practices for over-read vary by urgent care center and range from over-read of all images to selective over-read of:
- All active smokers;
- Patients over 35 with a history of smoking;
- All extremities below the ankle and/or below the wrist;
- All elderly patients;
- All head and neck injuries; and
- All pediatric patients.
Because of the variety of clinical presentations where an over-read by a consulting radiologist can reduce professional liability for the urgent care provider, most centers choose to send all images for over-read.
Typically, the urgent care center will bill both the technical and professional component where the urgent care provider makes the presumptive diagnosis using the image, and then sends the image to a consulting radiologist for over-read. In this scenario, the over-read is for confirmation or correction of the provider’s preliminary diagnosis and the consulting radiologist’s fee is simply part of the urgent care center’s operating overhead (meaning the center doesn’t charge separately for the over-read expense).
If a consulting radiologist is used to actually read the x-ray and provide a diagnosis, then the urgent care center that takes the x-ray bills the technical component (modifier –TC) and the consulting radiologist bills the professional component (modifier -26). This is a common practice in hospital-affiliated urgent care centers, where all x-rays are read by the hospital’s affiliated radiology group. Such is typically viewed as “downstream revenue” to the health system from the urgent care. In this scenario, the hospital radiology group will bill the patient’s insurance for radiologist’s service, which becomes the patient’s financial responsibility if the claim is rejected due to an unmet deductible. Patients typically resent receiving multiple bills for a single visit, after the fact, and this billing practice undermines the urgent care value proposition of simplicity and transparency in billing.
In addition, hospital radiology groups tend to be expensive because hospital radiologists are more focused on higher complexity modalities including CT, MRI, fluoroscopy, nuclear medicine and interventional radiology. To the hospital radiologist, over-reading x-rays can be a distraction and a poor value given the professional cost of their time. When a hospital radiology group is involved with x-ray reads, the cost can be as high as $300 to $500 (a multiple of the total cost of the urgent care visit) and turn-around can be as long as 2-3 days (undermining the urgent care provider’s need for immediacy).
Radiology over-read services focused on the urgent care industry add value to hospital urgent care operators through lower prices and faster turnaround than hospital radiology groups. Familiarity with the most common urgent care presentations and operating scale enabling extended-hours services in most states, for instance, enables Teleradiology Specialists to turn-around reads in less than 20 minutes at a cost of less than $10 per read.
Key to success in any urgent care radiology program is to balance the need to provide quality medical care, to control professional liability while also assuring x-ray remains an economical service for the urgent care center.