Feature | April 01, 2014| Dave Fornell

Congress Passes 12-Month SGR Patch, Delays ICD-10, Requires AUC

The legislation requires use of clinical decision support software and delays implementation of ICD-10 codes for one year

April 1, 2014 — The Senate passed the Protecting Access to Medicare Act of 2014 (H.R. 4302) March 31, in a vote of 64 to 35. The legislation delays a 24 percent Medicare physician payment cut for 12 months. The cuts were originally supposed to go into effect April 1. 

The law also makes large strides toward modernizing the American healthcare system by requiring evidence-based medicine. What may be first of its kind requirements included in the patch are aimed at making healthcare more efficient, raising medical imaging quality, improving utilization accuracy and making physician payment policy more transparent. This includes required use of appropriate use criteria and clinical decision support software.

The American College of Radiology (ACR) applauded both houses for passing the bill, which wards off massive provider payment cuts mandated by the flawed Sustainable Growth Rate (SGR) formula. This is the 17th patch that Congress has enacted since 1997. 
However, the American College of Cardiology (ACC) issued a statement saying the patch falls short of a repair or repeal of the flawed SGR legislation. The ACC said, “While the legislation includes provisions the ACC has advocated for within the scope of full SGR repeal, failure to permanently repeal the SGR given the significant bipartisan/bicameral legislative efforts this year represents a wasted opportunity to finally provide much needed stability within Medicare.”
There has been much discussion among physicians about the creation of appropriate use criteria and its possible utilization for reimbursement. The bill effectively accomplishes this by requiring ordering providers to consult physician-developed appropriateness criteria when prescribing advanced imaging procedures for Medicare patients. This provision is already a part of the federal Stage 2 Meaningful Use requirements for certified electronic medical record systems (EMR). 
The legislation directs the secretary of the U.S. Department of Health and Human Services (HHS) to identify mechanisms, such as clinical decision support systems, by which ordering professionals can consult these criteria. Such ordering systems reduce duplicate and/or unnecessary scanning and associated costs. This may be the first time that Medicare would require providers to use such point of care, evidence-based ordering for exams or procedures. 
“As medical imaging is the cutting edge of modern medicine, this requirement is 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. This will reduce unnecessary costs and help pave the way for a more responsive and efficient health care system,” said Paul H. Ellenbogen, M.D., FACR, chair of the ACR Board of Chancellors.    
“The imaging provisions in this bill will help remove the conjecture from health policy regarding how much imaging is necessary, whether patients are getting appropriate care and how efficiently America is using its healthcare resources,” Ellenbogen said. “For healthcare reform to truly advance, physicians, as well as patients, have to be comfortable that transparency works both ways. The imaging provisions in this bill are a major step forward for healthcare.”
?However, the ACR said it has concerns regarding the broad statutory expansion of the authority of the secretary of HHS to revalue Medicare physician payments based on a large number of criteria to be used at the secretary’s discretion.
Key provisions in the legislation include:
Prevents 24 percent cut scheduled for April 1, 2014, provides a 0.5 percent update through Dec. 31, 2014, and a 0 percent update from Jan. 1 through March 31, 2015
Requires consultation with appropriate use criteria (AUC) and clinical decision support (CDS) for advanced diagnostic imaging?
AUC must be developed or endorsed by professional medical societies?
CDS software must be available to providers at no cost?
Beginning in 2017, claims that fall under the AUC requirement will only be paid if they include data that indicate CDS tools that were consulted
Hardship exemptions are available (rural areas or insufficient Internet access)?
Beginning in 2020, the HHS secretary will identify outlier providers based on data from two previous years?
Outliers would be subject to prior authorization — no more than 5 percent of total providers?
Allows the HHS secretary to revise payments for potentially misvalued codes within the physician fee schedule based on information collected from providers?
Policy applies to fee schedule for years 2017-2020
Target for value reduction is 0.5 percent of the estimated amount of total fee schedule expenditures for the given year
If the total relative value unit for an identified misvalued code is scheduled to be reduced by 20 percent or greater due to the re-evaluation, the adjustment must be phased in over two years
Extends Health and Human Services (HHS) secretary's medical review activities regarding the "Two Midnight Rule" for the first six months of 2015?
Delays the transition to ICD-10 for one year?
Extends funding for the National Quality Forum for measure endorsement through July 2015?
Beginning January 2016, requires all computed tomography (CT) scanners to adhere to NEMA radiation dose standards?
Applies to fee schedule and Hospital Outpatient Prospective Payment System services?
Payment for services rendered with equipment not consistent with the above standards would be reduced by 5 percent in 2016 and 15 percent in 2017 and subsequent years?
Consolidates the 2 percent Medicare sequester cut scheduled for full year 2024 into a 4 percent cut in the first six months of 2024?
Require the Centers for Medicare and Medicaid Services to produce data used to justify a 25 percent multiple procedure payment reduction, instituted in 2012, to certain imaging procedures provided to the same patient, on the same day, in the same session.
For the full text of the legislation, go to www.gpo.gov/fdsys/pkg/BILLS-113hr4302ih/pdf/BILLS-113hr4302ih.pdf

Related Content

CT Shows Enlarged Aortas in Former Pro Football Players

3-D rendering from a cardiac CT dataset demonstrating mild dilation of the ascending aorta. Image courtesy of Christopher Maroules, M.D.

News | Computed Tomography (CT) | January 12, 2018
Former National Football League (NFL) players are more likely to have enlarged aortas, a condition that may put them at...
Siemens Healthineers Strengthens CT Portfolio With Four New Systems at RSNA 2017

The Somatom Force with the new FAST 3D Camera

Technology | Computed Tomography (CT) | December 14, 2017
December 14, 2017 — Siemens Healthineers introduced four new...
Toshiba Medical Introduces Aquilion Prime SP CT System at RSNA 2017
Technology | Computed Tomography (CT) | December 13, 2017
December 13, 2017 — Toshiba Medical, a Canon Group company, introduced its new Aquilion Prime SP...
Philips Debuts IQon Elite Spectral CT Scanner at RSNA 2017
Technology | Computed Tomography (CT) | December 11, 2017
At the 2017 Radiological Society of North America (RSNA) Annual Meeting, Philips unveiled the IQon Elite Spectral CT,...
Toshiba Highlights Ultra-High Resolution CT at RSNA 2017
News | Computed Tomography (CT) | December 06, 2017
Toshiba Medical, a Canon Group company, showcased the Aquilion Precision, what it calls the world’s first ultra-high...
Samsung Unveils Mobile CT OmniTom at RSNA 2017
Technology | Computed Tomography (CT) | November 26, 2017
Samsung Electronics debuted its OmniTom mobile 16-slice computed tomography (CT) scanner at the Radiological Society of...
Siemens Healthineers Announces First U.S. Installs of Somatom go.Up CT System
News | Computed Tomography (CT) | November 15, 2017
November 15, 2017 — Center for Diagnostic Imaging (CDI), one of the nation’s largest providers of diagnostic imaging
Medis Releases QAngio CT v3.1
Technology | Computed Tomography (CT) | October 09, 2017
Medis has released a new version of its QAngio CT (computed tomography), which can now be launched from the Medis Suite...
Hitachi Supria True64 CT Receives FDA Clearance
Technology | Computed Tomography (CT) | September 15, 2017
Hitachi Healthcare Americas Inc. announced it has attained U.S. Food and Drug Administration (FDA) 510(k) clearance to...
Orange County, Calif. Hospital Adopts Siemens Somatom Force CT for Cardiac Imaging
News | Computed Tomography (CT) | September 12, 2017
Hoag Memorial Hospital Presbyterian recently became the first hospital in Orange County, Calif., to install the Siemens...
Overlay Init