New Law Mandates Use of Imaging Appropriateness Criteria

Radiology leaders are lauding the latest SGR “Patch” bill as a victory for imaging and all of healthcare


Beginning in January 2017, referring physicians must use physician-developed appropriateness criteria when ordering advanced imaging for Medicare patients, in an effort to reduce duplicate and/or unnecessary scanning and associated costs.

The new provision, which also directs the secretary of the U.S. Department of Health and Human Services (HHS) to identify clinical decision-support (CDS) tools to help physicians navigate the appropriateness criteria, was approved April 1 as part of the Protecting Access to Medicare Act of 2014, or so-called sustainable growth rate (SGR) “patch” bill. The new measure also maintains current overall provider reimbursement for the next 12 months, preventing a 24 percent SGR-mandated physician pay cut.

Using the CDS tools embedded with appropriateness criteria is designed to improve the accuracy of ordering advanced diagnostic studies and ensure the appropriate studies are done for the right reason on the right patient.

Calling it a long time in coming, radiology leaders are lauding the provision—and other American College of Radiology (ACR)-backed measures in the legislation—as a victory for imaging and a big step forward for healthcare reform overall. Other changes mandate greater transparency around payment policy and improve patient safety through stricter controls on radiation dose levels.

“The provision is a major step toward appropriate use of medical imaging,” said James Borgstede, M.D., an expert in radiology economics, quality and safety and healthcare politics and the RSNA Board Liaison for International Affairs. “If referring physicians embrace this concept, it will provide significant improvement in patient care.”

But that’s a big “if” according to some radiology leaders who stress that implementing these initiatives will be considerably more involved than just contacting the IT department to install CDS tools. Buy-in and commitment from referring physicians will be critical to the initiative’s success, said Vijay M. Rao, M.D., RSNA Board Liaison for Information Technology and Annual Meeting.

“We can’t just provide a clinical support tool and expect it to work like a charm,” said Dr. Rao, the David C. Levin Professor and chair of Radiology at Jefferson Medical College of Thomas Jefferson University. “We need to educate referring clinicians on the importance of using these tools appropriately and approach this as a fully realized program requiring time and commitment.”

Timeline for Imaging Appropriateness

While the appropriateness criteria rule doesn’t go into effect until 2017, the bill provides a timeline for putting the process in motion.

By November 2015, HHS must specify applicable appropriate use criteria for imaging services, using guidance from national professional medical specialty societies, including ACR, and other provider-led groups. ACR has long advocated for the use of clinical decision support systems.

When the law takes effect, physicians who provide imaging services will only be paid for claims that include information about which CDS tool was used and documentation that it meets the standard. This could pose a problem for radiologists, since it would become their responsibility to make sure the ordering physician used the CDS tool properly and reported it.

Because new provisions put the onus on referring physician, it remains to be seen how seamlessly the process will be integrated into daily practice. It’s possible the task could fall into “the nuisance factor” category for physicians already dealing with significant workloads, said Dr. Rao, adding that CDS tools have been have yet to be tested on a large scale.

“We haven’t really done due diligence on the effectiveness of CDS tools,” Dr. Rao said. “As radiologists, we believe in the philosophy of reducing imaging tests, but for our clinical colleagues, we’re not sure they’re going to feel that way. That’s why the education element in it is so important to effectiveness.”

Data Sought for Multiple Procedure Payment Reduction

ACR also fought for a new provision that requires CMS to produce data used to justify a 25 percent multiple procedure payment reduction (MPPR) that was instituted in 2012 for a specific set of imaging procedures when they are provided to the same patient, on the same day, in the same session.

CMS contends the proposed cuts achieve efficiencies when multiple procedures are performed together. Calling the cuts “arbitrary,” radiologists point out they are obligated to devote the same time and attention to each image, and that there is no real time or cost saving in taking multiple scans at one time.

“This is another important provision in the bill, because it requires CMS to produce the scientific data to justify their indiscriminate 25 percent reduction on multiple procedures, which they have never been able to do,” said Dr. Borgstede, a professor of radiology and vice-chair of professional services, clinical operations and quality at the University of Colorado, Denver.

“Show us the data,” Dr. Rao added. “CMS wants us to practice evidence-based medicine, but they are making decisions on multiple procedure payment reduction without any data at all.”

CT Scanners Must Meet MITA Standards

Another ACR-backed provision creates stricter standards for managing CT dose. In January 2016, Medicare will begin reimbursing 5 percent less for CT scans that are acquired on technology that does not meet latest specifications for CT dose optimization published by the National Electrical Manufacturers Association’s Medical Imaging & Technology Alliance (MITA) in April 2013.

Requiring CT scanners to meet the 2013 standard is critical to ensuring the safety of patients, Dr. Rao said. “It’s our responsibility to expose our patients to the lowest radiation dose possible, and a lot of CT machines out there are outdated and are not properly maintained, so this is absolutely critical.”

Dr. Rao said she would like to see such standards expanded to include standard X-ray machines, which have fallen off the radar at CMS despite their large volume. “CMS is focused on advanced imaging because of reimbursement and cost, but when you look at the volume of plain X-rays, it really adds up, and there are no standards out there.”

Imaging Provisions Included in Healthcare Law

The “Protecting Access to Medicare Act of 2014,” (H.R. 4302) includes the following ACR-backed provisions:

  • Maintain current overall provider reimbursement for the next 12 months (avoiding a 24 percent across the board cut to provider payments statutorily mandated by the SGR formula).
  • Mandate that cuts to medical services greater than 20 percent (in comparison to the previous year) are phased in over a two-year period.
  • Require CMS to produce data used to justify a 25 percent multiple procedure payment reduction, instituted in 2012, to certain imaging procedures provided to the same patient, on the same day, in the same session.
  • Delay implementation of ICD-10 provider payment codes as ACR works to prepare radiology providers for the transition to this new system.
  • Improve patient safety through stricter controls on radiation dose levels delivered by CT machines.
    Radiology leaders are lauding the most recent SGR “patch”
    Radiology leaders are lauding the most recent SGR “patch” bill which includes numerous American College of Radiology-backed provisions including requiring referring physicians to develop appropriateness criteria when ordering advanced imaging for Medicare patients.

    Web Extras

    Beth Burmahl is the managing editor of RSNA News.