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The mission of the Harvey L. Neiman Health Policy Institute® is to establish foundational evidence for health policy and radiology practice that promotes the effective and efficient use of health care resources and improves patient care.

March 1, 2018

Radiologists Referrers for MSK Imaging

A new Harvey L. Neiman Health Policy Institute™ study analyzes the specialty characteristics of providers referring musculoskeletal (MSK) extremity examinations to radiologist, in order to better understand drivers of MSK imaging utilization and to potentially improve appropriateness. The report is published online in the American Journal of Roentgenology (AJR).

“MSK imaging utilization has substantially increased over the past two decades, most notably for MSK magnetic resonance imaging (MRI),” said lead study author and assistant professor of radiology at Emory University Paul Harkey, MD. “The increased utilization has been associated with greatly increased costs, with MSK currently projected to exceed $3 billion by 2020.”

Harkey and his colleagues extracted provider referral data for MSK extremity imaging from 2014 Medicare Referring Provider Utilization Files, which aggregate claims data by referring provider identities and service codes.  MSK extremity imaging services were identified utilizing Neiman Institute Types of Services (NITOS). Referring provider specialty was identified from cross-linked Medicare provider characteristics files.

Among 4,275,647 MSK extremity imaging examinations, the most common ordering specialties were: orthopedic surgery (37.6%); internal medicine (20.2%); family practice (14.8%); emergency medicine (7.9%); and rheumatology (5.7%). Orthopedic surgery was the most common referring specialty for MSK extremity CT, MRI, and radiography; internal medicine was most common referring specialty for MSK extremity ultrasound. The most commonly ordered individual MSK extremity imaging services were knee radiographs for orthopedic surgeons.

“Our analysis offers an initial largescale view of the ordering practices of physician specialties and may serve to begin the process of further exploring associated costs and downstream outcomes,” noted Andrew Rosenkrantz, MD, MPA, senior author and a Neiman Institute affiliate research fellow.

In the Medicare population, referral patterns for nonvascular MSK extremity imaging vary considerably by specialty. Overall, orthopedic surgery is the dominant referring provider. Understanding the unique specialty referral patterns of MSK extremity imaging will be useful for radiology practices to succeed in managing and optimizing utilization under emerging value based care paradigms.

To obtain a copy of the AJR study or to arrange an interview with a Neiman Institute spokesperson, contact Nichole Gay at (703) 648-1665 or



About the Harvey L. Neiman Health Policy Institute

The Harvey L. Neiman Health Policy Institute is one of the nation’s leading medical imaging socioeconomic research organizations. The Neiman Institute studies the role and value of radiology and radiologists in evolving health care delivery and payment systems and the impact of medical imaging on the cost, quality, safety and efficiency of health care. Visit us at and follow us on TwitterLinkedIn and Facebook.


Nichole Gay
Harvey L. Neiman Health Policy Institute