As I write this column, the Obama administration and the Congress are intensively discussing the elements of healthcare reform legislation. My guess is that most radiologists are not looking forward to either the specific cuts targeted at imaging being considered by Congress, or cuts contained in the proposed 2010 Medicare Physician Fee Schedule rule.

Nevertheless, one aspect of the proposed new fee schedule rule, if CMS tailors it correctly, could have a dramatic and positive benefit, and could significantly reduce physician in-office self-referral.

That part of the new fee schedule proposal is the new imaging accreditation rule. Providing that CMS actually sets out clear requirements for the general supervising physician (medical director) at an accredited imaging facility and makes it clear that practices must bill using the name and national provider identification number of that same general supervising physician, this could be a major reform!

For two years, CMS worked on developing its antimarkup rules, which were crafted to take much of the profit out of self-referral and, thereby, curtail utilization of diagnostic imaging services. Sadly, those regulations have been largely ineffective. That's because anyone in the referring physician group practice could be designated as “performing” a technical component procedure that must be performed under general supervision. Unlike at independent diagnostic testing facilities (IDTFs), those physicians who performed services were held to no proficiency standards when applying the antimarkup rule.

Medicare rules for IDTFs have long required that supervising physicians demonstrate “proficiency” in the performance and interpretation of the test they supervise and for several years CMS has been making an effort to strengthen those standards.

Over the last two years, CMS made several attempts to actually increase the responsibility of the general supervising physicians in IDTFs. In its ill-fated Transmittal 187, issued in late January 2007, CMS attempted to make clear that the general supervisory physician is responsible for what CMS called “the overall operation and administration of the IDTF.” Although this language was somewhat clumsy and subsequently withdrawn, it was clear that CMS wanted to make sure that those physicians designated as supervising physicians actually were providing general supervision. The Medicare Supervision Rules define general supervision as “the physician's overall direction and control, but the physician's presence is not required during the performance of the procedure.” CMS felt that too much attention had been given to the “presence is not required” aspect of that definition, but not enough to the responsibilities for overall direction and control.

Most readers of Diagnostic Imaging are also aware that for the last three years, CMS has been strengthening its IDTF regulations found at 42 C.F.R. 410.33. Under the newly revised rules, the general supervising physician's role is considered so important that each of them is limited to supervising no more than three IDTF sites (whether fixed or mobile). Clearly, CMS has recognized that the role of the general supervising physician is vital to the quality of the imaging services provided at any given IDTF site.

The 2010 proposed fee schedule contains accreditation standards for advanced diagnostic imaging services that will be required beginning in 2012. Both the American College of Radiology and the Radiology Business Management Association have offered significant comments that, if adopted, would constitute a major step toward both ensuring quality and patient safety and curtailing many self-referrals to advanced imaging services in physician offices.

The two organizations have recommended that CMS require general supervising physicians (“medical directors”) of accredited facilities to demonstrate proficiency in the performance and interpretation of the advanced imaging services they supervise. This proficiency requirement would not apply to a physician who directly supervises contrast studies.