Much uncertainty and little industry awareness surround a new program that will require physicians ordering outpatient radiological procedures for Medicare beneficiaries to justify ahead of time that the imaging is necessary.
The reimbursement approach aims to have physicians refer to industry-developed appropriateness criteria before ordering advanced—and expensive—imaging procedures for patients, using clinical decision support modules that will be tied into organizations’ electronic health records systems.
The program, one of the provisions of the Protecting Access to Medicare Act of 2014, will go into effect on Jan. 1, 2018, but many specifics of how the program will work are still in development, said presenters at a session during the annual meeting of the Radiological Society of North America.
The use of criteria is expected to be applied to imaging studies ordered for outpatients for eight types of studies, termed priority clinical areas—coronary artery disease, suspected pulmonary embolism, headache, hip pain, low back pain, shoulder pain, cancer of the lung, and cervical or neck pain, says Joseph Hutter, MD, a lieutenant commander in the U.S. Public Health Service.
The program will have significant effects on ordering physicians, radiological professionals and healthcare organizations, which will need to add imaging-specific modules to their EHR systems and adjust workflows. In addition, it could impact payments for radiology professionals in 2018 and force a small percentage of physicians who regularly override appropriateness criteria to seek pre-authorization for studies beginning in 2020.
Criteria to justify advanced radiological procedures for those clinical reasons have been hammered out by RSNA and other professional organizations, presenters say. Before physicians order tests, they’ll need to use a clinical decision support module, expected to be embedded in their EHR systems.
The program has been developed through a partnership between the Centers for Medicare and Medicaid Services and several professional radiological groups as a way to ensure that imaging services such as MRI, CT and nuclear medicine scans meet appropriate use criteria. The intent of the effort is to reduce duplicate or unnecessary procedures, says Curtis Langlotz, MD, professor of radiology at the Stanford University Medical Center.
Ordering physicians can choose to override the decision on appropriateness provided by the module, but results will be compiled over time to assess how regularly physicians comply, or don’t comply, with appropriate use criteria, Langlotz says. By 2020, the top 5 percent of physicians overriding CDSM decisions will be considered outliers and will need to have orders for advanced radiological procedures subject to pre-authorization.
When the program starts in 2018, it will have an immediate impact on radiology professionals. Physicians that use CDSMs to assess the appropriateness of procedures will receive a code from the module, which radiologists will need to submit on claims sent for payment to Medicare. Radiologists that don’t submit the code to CMS won’t be paid, Hutter says.
The program is an effort to justify the use of procedures to reduce duplication and medically unnecessary testing, and is unique in that professional organizations participated in developing the criteria, says Keith Dreyer, DO, vice chairman and associate professor of radiology at Massachusetts General Hospital.
The initiative is an attempt to enable professional input into what types of tests are appropriate for certain diagnoses, instead of using pre-authorization or radiology benefit management programs (RBMs), which typically “are formed to serve payers,” Dreyer says. “They manage cost and not care, and downstream provider consequences are not a concern for RBMs.”
Nonetheless, many specifics of how the program will operate will be developed over the coming year, Hutter says, particularly how CDSMs will fit into providers’ EHR systems or how workflows will need to be adapted.
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