Important provisions of the Protecting Access to Medicare Act of 2014 that warrant radiologists’ attention

The flawed Sustainable Growth Rate (SGR) formula is a dark cloud of uncertainty that annually hangs over healthcare practitioners, threatening to trigger the government-mandated double digit cut in reimbursement rates for Medicare beneficiaries. When the temporary SGR patch was extended in April 2014 (for the 17th time), it was the inclusion of the ICD-10 delay that took healthcare by surprise and overshadowed other provisions of the Act. While the ICD-10 delay certainly warrants the attention of healthcare providers, there are other provisions included in the Protecting Access to Medicare Act (PAMA) of 2014 that deserve equal attention so that clinicians can prepare for the impending changes. Harry Purcell, operations manager and Missy Lovell, compliance manager of Zotec Partners, urge radiologists to consider the importance and impacts of the provisions related to the promotion of patient safety in CT diagnostic imaging, as well as the mandate of appropriate use criteria and clinical decision support tools when ordering advanced diagnostic studies.

Incentives to promote patient safety in CT diagnostic imaging

Within the newly passed legislation, provisions dedicated to medical imaging were introduced as they relate to patient safety to more strictly control CT dosage requirements under NEMA Standard XR-29-2013. The standard identifies common CT system attributes that contribute to or help perform optimization/management of doses of ionizing radiation while still enabling the system to deliver the diagnostic image quality needed by the physician.  Specifically, HCPCS codes 70450–70498, 71250– 71275, 72125–72133, 72191–72194, 73200–73206, 73700–73706,74150–74178, 74261–74263, and 75571–75574 (and any succeeding codes) are subject to this regulation.

“Effective January 1, 2016, Medicare providers must ensure that the CT equipment they’re operating meets the NEMA Standard,” says Purcell. “The current estimate is that a little more than a third of the CT equipment being used today does not meet that standard.”

Those providers who continue to operate equipment that does not meet the standard will face progressive reductions in reimbursement to the tune of 5 percent in 2016, and 15 percent in 2017 and each year thereafter.  

“If facilities determine that the replacement or upgrade of their units is too costly, as much as one third of CT equipment could be leaving the marketplace, impacting the overall volume of CT studies (and thereby reducing the cost of imaging in healthcare), but it also presents an imaging access issue to healthcare consumers,” adds Lovell.

While theoretically, the provision seems a viable way to reduce costs and improve care, there will be financial impacts to radiology groups and imaging centers.

“The options for imaging providers may seem black and white at first,” says Purcell. “Reassess your CT equipment. If an upgrade to meet the new standard is not possible, weigh the cost of a capital equipment investment versus the financial impact of decreased reimbursement relative to your patient volume. However, because this is a matter of patient safety, it will be equally important for an imaging center to operate equipment that delivers the least radiation exposure to patients or they may risk losing market share.”

The CT equipment rule is not only applicable to freestanding imaging centers, but to hospitals’ outpatient imaging services as well. It does not apply to hospital inpatient services. However, operating CT equipment that meets the NEMA standard should be on the radar of every imaging center and radiology practice, according to Purcell and Lovell.

The path to finalizing appropriate-use criteria

In addition to the CT equipment standard mandate, the PAMA included a mandate that beginning January 1, 2017, any physician ordering advanced diagnostic imaging exams must first consult HHS-sanctioned appropriate-use criteria. HHS must publish the final accepted criteria by November 15, 2015, using evidence-based data collected from various provider-led organizations such as the American College of Radiology. Specifically, the law states the criteria must, to the extent feasible, be based on studies that are published and reviewable by stakeholders.

Once finalized, ordering physicians must consult the criteria prior to ordering advanced imaging studies, which include CT, MRI, nuclear medicine and PET. These consultations will not apply to inpatient services and to those ordering practitioners who meet certain hardship criteria.  Assumedly because of the potential administrative burden this would put on ordering physicians, as well as on the reimbursement process, the law also mandates that ordering physicians confirm the appropriate-use criteria were consulted prior to the exam through the use of a clinical decision support system (CDS). The law does not specify that the physician ordering the exam must adhere to the appropriate-use criteria, but rather, the claim for the exam must be submitted with evidence that the criteria were consulted. 

“While the administrative aspect of the new workflow remains with the radiologist to tag each claim to show the ordering physician consulted the guidelines, ultimately, the mandate should reduce the number of medical necessity denials to the group,” explains Lovell.

Because the law mandates that providers utilize CDS tools, the HHS is also tasked with vetting the CDS tools and creating a process whereby CDS vendors can be deemed certified, similar to the electronic health record (EHR) certification process within the meaningful use program. By April of 2016, HHS must publish qualified clinical decision support mechanisms that ordering practitioners can consult. 

So it seems providers are facing yet another “incentivized” financial investment in technology with a significant potential impact to revenue for noncompliance, but unlike EHRs, this investment should not be as substantial.

“We are really hoping that the cost of the CDS programs will not be terribly significant for providers,” says Lovell. “Clinical decision support is a wonderful tool to cut down on unnecessary testing. As a result, radiologists should expect to see a significant increase in billing efficiencies through reduced medical necessity denials,” she adds.

“The benefits should really outweigh the costs to participate in these programs,” adds Purcell. “The idea behind the federal program is to reduce unnecessary exams, radiation exposure to patients, and the cost of imaging in healthcare, and the new legislation is setting up some guidelines for providers to be successful in each of those areas.”