It is becoming less common for every chiropractor to have an x-ray facility in his own office. With increasing frequency, chiropractors decide that they want to refer out for x-ray services. Sometimes they ask a fellow chiropractor to produce x-rays for them. This leads to a question of whether it is legal for a chiropractor to produce x-rays on a technical basis at the order of another doctor.
The short answer to this question is “Yes, it is fine to do this — if you want to — but watch out for that ‘want to’ part!”
Before you decide whether you want to take x-rays for another doctor, it is vital for you to consider one thorny problem: Who is going to interpret the x-rays?
Professional standards and case law certainly make it quite clear these days that someone must be officially responsible for interpreting the x-rays and providing a report to the patient, as well as for archiving that report as a part of the patient’s health care record.
If you, as the doctor who produces the films, are going to be interpreting the x-rays, you must decide whether you are comfortable with signing an official written report of radiologic findings for a patient who is not your own patient. For a DACBR or other radiologist this is an expected part of doing business, but a general practice DC may or may not want to assume this responsibility for himself, even though it is legal for him to do so.
If you decide that you do not want to fill this role, it may initially sound easier to simply expect the referring doctor to interpret the x-rays. The referring doctor may even be quite happy to do this — and may even expect it — but it is not as easy as it sounds.
There’s always a liability question lurking in the background. What happens if the referring doctor misses a diagnosis? What if that mistake causes damages for the patient? There would, of course, be a lawsuit filed. It would not, however, name only the referring doctor. The malpractice suit would also name the doctor who produced the x-rays. Admittedly, it’s an unusual circumstance, but it is wise, as a matter of routine risk management, to prepare for this unfortunate circumstance by not entering naively into a situation with potential liability over which you yourself have little control.
In malpractice cases, vicarious liability always seems unfair, but it is a fact of life that cannot be avoided by ignoring it.
If you decide that you want to produce x-rays on a technical basis for another doctor, be sure to first obtain good legal advice. It is probably not possible to entirely avoid vicarious liability, but a few things might help to reduce the risk.
The first factor, always the most important, is to make sure that the patient is informed and completely understands the service being provided. Your attorney may advise the use of a informed consent document that specifies the respective responsibilities of the two doctors involved. For example, the document might specify that the x-rays are being taken on a technical basis by Doctor A, and that Doctor A is responsible only for ensuring that they are produced in a safe manner and are of diagnostic quality, whereas Referring Doctor B is responsible for the interpretation of the x-rays. In some offices Doctor A might employ an x-ray technician who produces the x-rays. In this case, the informed consent document could notify the patient that Doctor A does not even see the x-rays, and that the patient’s treating doctor B is responsible for all factors relating to interpretation and provision of information to the patient.
Your attorney would also need to assist you in drawing up a contract between Doctor A and Referring Doctor B. Each doctor should make sure that the other has an active malpractice policy, and should be certificate-holders on those policies so that each receives a copy of the other’s declarations page with each annual renewal.
It would also be a good idea to consider HIPAA factors, although any covered health care provider may share Protected Health Information with another health care provider for treatment purposes without a Business Associate Agreement. At any rate, privacy provisions might be something to consider in the contract.
Once these factors are handled, it is then necessary to determine the proper way to bill for services:
- If Doctor A both produces and interprets the x-rays, he then bills for the global service in a typical manner. Referring Doctor B could then bill for an office call to discuss the findings with the patient.
- If Doctor A produces the x-rays and Referring Doctor B interprets them, it is not legal for either doctor to bill for the global service and have an arrangement on the side to handle the finances. Instead, each doctor must provide his own billing.Doctor A bills only for the technical component. This is accomplished by using the proper code for the x-rays in question, and by adding -90 to indicate a “reference lab.”Referring doctor B bills only for interpreting the x-rays. This is accomplished by using the proper code for the x-rays in question, and by adding -26 to indicate the “professional component.” Fees, of course, are established at the discretion of each facility, but it is quite common to charge approximately 60% for the technical component and 40% for the professional component.