Radiologists await proposed rules for appropriate use criteria

CMS expected to outline plan that would require prescribing physicians to use clinical decision support rules to justify advanced imaging procedures.

____simple_html_dom__voku__html_wrapper____>Timeframes are tightening for radiology groups that will be reimbursed by Medicare in 2018 for advanced imaging studies on outpatients, as the industry still awaits a proposed rule for how the program will work.

That rule could come as soon as this week, says Melody Mulaik, president and co-founder of Coding Strategies, during an educational session at the annual conference of the AHRA, The Association for Medical Imaging Management.

But even if proposed rules drop soon, Mulaik told attendees that it’s unlikely that the industry would have final rules before November, which will leave the industry only a couple months to implement the rules before they are supposed to go into effect on January 1.

“We won’t know the final rule until November 1 at the earliest, and two months before a January 1 go-live won’t be enough time to get information systems ready,” she contends.

AHRA and other industry groups continue to press the Centers for Medicare and Medicaid Services to delay implementation of the rule past the scheduled implementation date, Mulaik says.

Under the program, physicians who prescribe advanced radiology procedures, such as MRIs, CAT scans and PET scans, will need to use a clinical decision support approach to ensure that radiological procedures meet certain pre-requirements, called appropriate use criteria (AUCs).

The program will be used to apply criteria to eight priority clinical areas:
  • Coronary artery disease (either suspected or diagnosed)
  • Suspected pulmonary embolism
  • Headache (traumatic and non-traumatic)
  • Hip pain
  • Low back pain
  • Shoulder pain (including suspected rotator cuff injuries)
  • Cancer of the lung (primary or metastatic, suspected or diagnosed)
  • Cervical or neck pain
The criteria were established by professional radiology organizations and providers, which have established rules for when advanced imaging procedures are warranted for those conditions, Mulaik says.

The program will not be used to pre-authorize procedures for Medicare beneficiaries, says Sheila Sferrella, president of Regents Health Resources, during the educational session at the conference, in Anaheim, Calif. Rather, physicians that refer patients to radiologists will need to use the clinical decision support rules when submitting orders for imaging procedures. Physicians can still order the procedure, and radiolgists will be reimbursed for performing them.

However, the program’s enforcement aspect takes hold in 2020, as CMS will use the data to identify the 5 percent of clinicians who are “outliers,” meaning they most frequently prescribe advanced imaging procedures that are not warranted under the appropriate use criteria. Those outliers then would be required to obtain prior authorization for services in 2020.

The rules will not apply to physicians who treat hospital inpatients or emergency department patients, Mulaik says.

But those are just the bare bones of the program, and the industry needs the final rules to see how CMS plans to operationalize the program.

For example, it’s not yet clear how prescribing physicians will get the codes to radiologists as part of their workflow or through electronic transfers. In addition, about 30 percent of orders for radiological procedures are received on paper, further complicating workflow, Sferrella says.

The program will be challenging to implement because ordering physicians needs to select the right appropriate use code, but the responsibility will fall back to the radiologists to get the right code from the referring physician and provide it to CMS.

“We can’t police all of our ordering physicians,” Mulaik says.

Premier Health, a five-hospital system in the Midwest, tried to implement a program to get its prescribing physicians to use criteria in ordering advanced radiological imaging studies, says Jacqui Rose, director of medical imaging and telecommunications for the system. It used “Choosing Wisely” criteria for procedures from the American College of Radiology.

Premier wanted to implement a criteria program for radiological procedures because it offers a health insurance program and it thus had a financial incentive to control utilization of imaging studies. Despite significant effort and planning, the system was not able to identify any significant benefits from the effort.

“No goals were established, no criteria for deciding what would be a success,” she told attendees. “Feedback and accountability were not provided to ensure changes in behavior.”

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