Radiology Healthcare Compliance: Are Stark Laws Self-Referral?



What does the Stark law tell us? What is it about? And you know, many people refer to it as the self-referral law which has, you know, in and of itself is not necessarily that descriptive. What does it say? Go trough this expert guidance provided by our expert in a healthcare conference.

It's the underlying requirement is actually pretty simple and it's its interpretation that's caused so many headaches. Basically a physician - and that's defined as a medical doctor but it's also other types of doctors as well. It could include dentists, psychologists and so forth.

But if you're in that category that - let's just talk about an MD, cannot make a referral for what's called a designated health service, DHS as defined term, to an entity or what we would call the referral recipient where the physician, the referring person, or his family have a financial relationship. Financial relationship being either an ownership, being compensation, being both, you know, one of the three.

Now, to ensure healthcare compliance, if you have those three components -- you got the doctor, you got the financial relationship, you're referring for DHS to an entity that you have the relationship with, then the Stark law is really simple. You can't make that referral. You can't get paid for whatever that referral generates, let's say it's a test or it's an interpretation of a test. You know, you're not supposed to get paid for it because you're not supposed to be able to make that referral.

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The thing though is, everybody gets excited about is unless an exception applies. And it's really the exception where, you know, you're getting into a lot more detail and trying to determine if you can go forward even though you have a financial relationship because you're accepted out of the walk.

Now, what is DHS because that's where you got the Stark with. Because if you don't have DHS you don't have to worry about this law. You know, if you're referring for something other than what's on the list and it, you know, that there's a lot of different things. Sometimes - let's say you're referring for a physician service that does not involve radiology, does not involve any of the other DHS services, that by itself may not cause a problem under Stark. And so, it becomes again important to know exactly what it is you're referring and best to get it under a CPT code.

Under radiology though - diagnostic imaging, the law has some descriptive terms but it also has CPT listings too. The law says that it includes outpatient radiology of diagnostic imaging, radiation therapy and even hospital services that may include radiology. So, if you're in one of those categories and that's what's being referred, then you have to be concerned about the law.

Healthcare Training Tip: In case of invasive diagnostics or what they call secondary procedures where the imaging is used as - let's say to help a surgeon do a surgery may not also be considered DHS. But it really does come down to the best way to determine it rather than relying on those words which are not very descriptive - they're descriptive but they're not very detailed, is to understand that Medicare every year issues a list of CPT codes that it considers to be DHS.


Now, it's not everyone of these numbers. But if you're in the range of 70,000 to 74,000, 76,000 to 78,000, 91,000 or 93,000 - if that's the CPT medical codes you're dealing with you got a good shot that it's considered DHS. The best way is actually go online. You go to the CMS website. Look under designated health service and you'll see an Excel sheet that - you can actually download it, that, you know, lists every single one of the CPT codes that it considers to be DHS. And they do that on an annual basis.


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