Imaging appropriateness rides in on SGR fix

In a landmark achievement for the American College of Radiology, Congress passed legislation that preserves physician reimbursement for 12 months and requires them to consult appropriateness criteria prior to ordering advanced imaging for Medicare patients.

Paul Ellenbogen, M.D., F.A.C.R., chair of the ACR Board of Chancellors, referred to the news as a major step forward in health-care reform. “Providers will have the latest medical evidence at their fingertips before a scan is ordered — ensuring that patients get the right exam for their condition and avoid unnecessary care,” he said in a prepared statement. “This will reduce unnecessary costs and help pave the way for a more responsive and efficient health care system.”

The development represents a blow to the radiology benefits management companies that provide pre-authorizations for advanced imaging in the private sector, which were recommended in the President’s 2015 budget as a method to control Medicare costs. Both referring physicians and radiology providers have complained about the added administrative costs of obtaining pre-authorization.

Many questions remain to be answered in the coming months, while the secretary of the U.S. Department of Health and Human Services determines the methods by which physicians may consult appropriateness criteria.

The Access to Medical Imaging Coalition lauded Congress for passing the legislation: “We are encouraged by the inclusion of an appropriate use criteria policy to ensure proper use of medical imaging, rather than calling for restrictive, across-the-board reimbursement cuts for imaging services,” Tim Trysla, executive director of AMIC, said in a prepared statement. “The best way to support physicians in ordering the right diagnostic imaging scan at the right time is for Medicare to encourage physicians and patients to make treatment decisions that best suit individualized needs and circumstances.”

The American Medical Association, which urged Congress to not pass the patch, and pass instead the bicameral, bipartisan bill to replace the SGR (which also includes the requirement to consult appropriateness criteria), issued a terse statement attributed to AMA President Ardis Dee Hoven, M.D.: “The American Medical Association is deeply disappointed by the Senate’s decision to enact a 17th patch to fix the flawed Sustainable Growth Rate formula. Congress has spent more taxpayer money on temporary patches than it would cost to solve the problem for good.”

Nonetheless, the AMA had championed a delay in the implementation of ICD-10, also required by the legislation for a minimum of one year. The delay of ICD-10 was supported by the ACR and many other specialty organizations, but organized healthcare billing and coding urged Congress to resist any further delays and get on with implementation.

Several other measures directly impacting radiology are included in the legislation, notably a requirement that CMS must produce the data that it used to justify a 25 percent multiple procedure payment reduction to specified imaging procedures provided to the same patient/same day/same session; and a mandate to improve patient safety through stricter controls on radiation dose.