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Changes Required to Receive Medicare Payment

March 9, 2009
Written by: , Filed in: Diagnostic Imaging
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Beginning in 2012, any non-hospital supplier of technical components of “advanced” medical imaging procedures — MRI, CT, and nuclear imaging including PET — will have to be accredited by an organization designated by the federal government if the imaging facility wishes to be paid for services to Medicare beneficiaries.

That provision, and one which sets standards for medical directors, supervising physicians, and imaging centers is part of a larger bill, House Resolution 63-31, which was passed by Congress in July to postpone the imposition of nearly a 11% cut in Medicare fees to physicians under existing Medicare sustainable growth-rate formula applications.

The reduction is now deferred to the end of 2009 and a 1.5% increase is granted during the same period.

While the new program will recognize the competence of radiologists to perform the advanced imaging procedures, it also provides for other medical organizations to accredit their members to operate imaging facilities and, presumably, to interpret imaging procedures performed in those facilities.

The provisions for imaging standards in the recently passed bill are to take effect January 1, 2012. By January of 2010, the government “will designate organizations to accredit suppliers furnishing the technical component of advanced diagnostic imaging services”. The bill authorizes spending $10 million on a two-year demonstration projection to test the proposed federal program.

The American College of Radiology (ACR) should qualify as an accrediting agency based upon its participation of mammography facilities in cooperation with the public health service, and the state radiation control programs that license x-ray facilities plus its voluntary accreditation programs for other imaging technologies.

Whether the ACR will qualify facilities owned by other physicians, or how other medical societies will qualify to accredit facilities owned and operated by their members, remains to be determined. The new law also specifies criteria to evaluate suppliers of technical components of the advanced imaging suppliers.

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Criteria are to be specific for each modality — CT, MRI, and PET— and will include:

  • standards for qualifications of medical personnel who are not physicians and who furnish the technical component of advanced diagnostic imaging services
  • standards for qualifications and responsibilities of medical directors and supervising physicians including standards that recognize the considerations defined subsequently
  • procedures to ensure that equipment used in furnishing the technical component of advanced diagnostic imaging services meets performance specifications
  • standards that require the supplier to have procedures in place to ensure the safety of persons who furnish the technical components of advanced imaging services and individuals to whom such services are furnished
  • standards that require the establishment and maintenance of a quality-assurance and quality-control program by the supplier that is adequate to ensure the reliability, clarity and accuracy of diagnostic images produced by such suppliers
  • any other standards or procedures the program deems appropriate.

The American Medical Association and most other medical organizations including the ACR have devoted major effort to resisting the cut in payment of physician fees. The provisions for imaging qualifications met with little opposition from other disciplines whose members will be affected by these requirements.

The terms of the bill do not exclude other physicians, but they seek to impose standards which should improve quality and might well have the effect of deterring physicians who cannot or chose not to meet criteria for imaging developed by their own specialty societies.

The very fact that a variety of medical specialties will be required to define medical imaging as related to their own disciplines is a significant change, with potential effects yet to be determined.

In the mid 1990s, Congress recognized the self-referral of imaging to facilities owned by physicians as a problem, and enacted two bills that sought to impose restrictions on self-referral of imaging procedures and other medical services. However, loopholes in the legislative language restricted the effectiveness of the legislation.

Now the law recognizes that other physicians accredited by standards set by their own organizations will be paid for imaging services and facilities owned and operated by them. The new law applies only to CT, MR and PET, and not to basic x-ray, fluoroscopy and ultrasound, which are legally defined as radiology.

As with most laws, the creation of supporting regulations and definitions will determine the impact of the legislative intent on uses of medical imaging. How much, for what, and by whom?

The ACR made its point, that the growth of volume in imaging and the added radiation exposure is not medically justified by a lack of restrictions on who can do what kinds of imaging. How effective this legislation will be will require the continued efforts of radiologists. Those efforts should be well worthwhile.

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