Understanding the underlying principles and details of CTA can help optimize dose and improve diagnostic quality for pediatric patients.

10 Things to Know About Pediatric Body CTA

Welcome to Diagnostic Imaging. I’m senior editor, Whitney Palmer. Before we get to our highlighted interview of the week on technology tools to improve patient engagement, here are the top stories of the week.

Across the country, the overall use of diagnostic imaging with pediatric patients is on the rise. According to a study published this week in 

, investigators from the University of Pittsburgh Medical Center revealed emergency departments are ordering more MRI scans and ultrasounds for children, but the numbers of CT scans are dropping. By examining more than 26 million emergency department records gathered between Jan. 1, 2009, and Dec. 31, 2018, the team calculated ultrasound use increased from 2.5 percent to 5.8 percent of patients, and MRIs increased from 0.3 percent to 0.6 percent. CT fell from 3.9 percent to 2.9 percent, declining in eight areas. Concussion saw a 23-percent drop; appendectomy a 14.9 percent; ventricular shunt procedures fell 13.3 percent, and migraine and other headaches reduced by 12.4 percent. Nervous system disorders dropped by 10.1 percent, abdominal pain by 6.1 percent, ear, nose, and throat by 5.9 percent, and seizure by 5.3 percent. The team also determined that more imaging was used for patients who were ultimately hospitalized.

After several years of waiting, it finally looks like the appropriate use criteria first introduced in the Protecting Access to Medicare Act of 2014 might be approaching full implementation. In a session during the Radiology Business Management Association’s PaRADigm Shift 2020 virtual meeting, coding and reimbursement expert Melody Mulaik, president of Revenue Cycle Coding Strategies, LLC, 

 where the industry sits with testing compliance to these guidelines and the use of clinical decision support. In her presentation, she outlined the G-codes – and the CPT modifiers – that must be included on claims to indicate your referring providers have consulted the appropriate use guidelines. Without these codes, once full implementation occurs, your claims will be denied when you submit for reimbursement. She also outlined several metrics by which you can gauge compliance. She suggested examining utilization by provider and practice both pre- and post-implementation, as well as evaluating primary and secondary payer denials, distinguishing between appropriate use criteria and medical necessity rejections. In addition, she recommended identifying any missing appropriate use criteria information by providers and facility staff to identify where omissions occur most frequently, and segmenting out compliance by modality when appropriate.

Over the past several months, it has become clear that the pandemic has touched radiology in a myriad of ways. In fact, the impact has seeped down to the residency program level as potential applicants and program directors are struggling to find alternative ways to meeting in person. In an article published in the 

Journal of the American College of Radiology

, a multi-institutional group of residency program leaders pointed to several tactics residency programs of all sizes can use to distinguish themselves from the pack when online interaction is the only format available. In addition to keeping static websites up-to-date with the latest program information, the program directors highlight social media and video conferencing as effective tools, as well. With social media they advocated for recruiting current residents and faculty to create photographic, written, and video material that can showcase the program’s high points. Featuring resident achievements on Facebook, Twitter, and Instagram accounts – especially those manned by the residents themselves – can also be effective. For video conferencing, the directors suggested standardizing backgrounds and equipment, as well as incorporating institutional logos. Using video tools to conduct mock interviews, host question-and-answer sessions with individuals who have recently gone through the Match, and plan virtual happy hours are also great ways to give potential applicants and clear idea about personality of a residency program.

And, social media is making headway into radiology beyond helping residents choose a program. In a new study published in 

, investigators from Louisiana State University Health New Orleans School of Medicine tested whether the time-constrained app Snapchat could be an effective tool in training residents in emergency room image interpretation. The answer is yes. During a four-week study, researchers presented seven residents – four juniors and three seniors – with five emergent radiologic cases using Snapchat and five similar cases using an overhead projector in the classroom. Across the board, the residents performed better with Snapchat. The cumulative score among juniors was 81 out of 160 with the app and only 63 with the classroom projector. For seniors, their cumulative score was 88 out of 120 with Snapchat and 75 with the projector. The hope, the researchers said, is that these results will help promote active learning and engagement in remote teaching environments.

 looked at the efforts to improve care delivery, specifically with patient engagement. In today’s environment, technology has become a powerful tool in improving these interactions. Across the board, it is being used to augment patient knowledge, skills, and interest in participating in his or her healthcare. Not only does it enhance communication with patients, making them feel more empowered, but it can also increase patient satisfaction rates. We spoke with Dr. Alexander Towbin, associate chief of clinical operations and informatics and chair of radiology informatics at Cincinnati Children’s Hospital Medical Center about his facility’s experience with the role of technology in patient engagement, as well as some best practices. Here’s what he shared.

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Pediatric Imaging Increase, Appropriate Use Criteria, Radiology Residency Pandemic Branding, Snapchatting Emergency Images

Diagnostic Imaging's Weekly Scan: Aug. 7, 2020

Maybe you pursued a leadership role in your practice. Maybe you stumbled into one by accident or out of necessity. How you came into the position is less important than how well you execute it – but not everyone innately knows how to be effective as the person in charge.

To put you on the path for being a better leader, Mary Kelly, Ph.D., CSP, retired U.S. Navy Commander, offered seven tips during an Aug. 5 Radiology Business Management Association (

) PaRADigm Shift 2020 virtual meeting session that can strengthen your leadership skills and put your practice and your staff and colleagues on a road to greater productivity.

“People want to do a good job for you, but sometimes the processes aren’t in place to make that happen. So, it’s a struggle,” she said. “Your physicians, staff, and patients are looking to you for solutions.”

 Mission statements are great, she said, but you need a vision for your practice. Where do you want your practice to be, and what do you want for your colleagues?

“Employees need a leader to have a clear, forward-thinking vision,” Kelly explained.

Identifying your vision is not difficult, but there are several things to consider. Take the time to think about what your practice currently does and what major changes might be coming your way. Outline your service goals for the next five, 10, and 20 years, and craft the legacy you would like to leave. Consider what you would do with your practice if you had no constraints, and use these thoughts to fashion your vision.

 According to Kelly, 58 percent of most employees have reported they would trust a complete stranger before they would trust their boss. You can avoid falling into this category by being truthful, providing information, and respecting your employees’ time. Avoid creating uncertainty and only set attainable goals. Do not gossip, name call, or make your employees and peers feel you are disloyal.

“Small things can lead to big problems,” she said. “But, with your words and with your behaviors – the more attention you give and the more you show that your employees’ opinions matter – the more they will trust you.”

 Try to eliminate any confusion in your staff about priorities by providing clear guidance toward goals, and remove any protocols or processes that might impede progress. Help you employees stay focused by checking in with them more frequently, and give them smaller goals so they can see more accomplishments.

 Actively show people that their presence and their contributions matter to you and your practice, Kelly advised.

“Your job is to care about the people who give you their time,” she said. “If you don’t show you care, they will quickly stop caring.”

One of the best ways you can demonstrate that you care is to streamline policies that can help you employees re-claim some of their time during the day, showing them you value their time and allowing them to be more productive. And, take the time to acknowledge their work.

 Even if you are not unfair with your employees, Kelly explained, it is possible they can misconstrue your actions as being that way. But, you can side-step this problem. When you make decisions or announce changes, share your reasons for doing so, and work to equally distribute responsibility throughout the office. Be sure you are not focusing too much on the staff you consider to be your “go-to” employees – as for input or volunteers when new projects or initaitives arise, and hold everyone accountable for their own work and productivity.

 While energizing your colleagues around a common goal, do not forget to capitalize on their unique characteristics and skills, Kelly said.

“Look at your employees and find the magic – embrace their differences because that is what makes them special,” she said. “This is also where you can show them their value, and it will lead to better ideas and fresher perspectives.”

As the leader, it is your job to support everyone within your organization from your direct reports to the patients you serve, and if you show everyone their contributions to the team are appreciated, the group overall will become more tightly knit and effective.

 Focus on the solutions, not the blame when things do not work quite right. This type of mentality will encourage your employees to take risks and think creatively.

“If you blame people, they will probably stagnate,” she said. “And, you need your employees to be innovative so they can better support your patients.”

Above all else, Kelly advised, lead with confidence – not arrogance – and your employees will be motivated to do their best for you.

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From fashioning a vision to creating a cohesive team to fixing problems, these leadership strategies can strengthen your practice and improve productivity.

RBMA: 7 Leadership Tips to Improve Your Practice

Regulatory compliance in radiology can sometimes be difficult. While you might be aware of the overall areas where you need to pay close attention to the rules, understanding and abiding by all of the ins-and-outs can be burdensome and complicated.

In an Aug. 5 presentation during the Radiology Business Management Association (

) PaRADigm Shift 2020 virtual meeting, W. Kenneth Davis, Jr., a partner with the law firm Katten, discussed the various compliance areas that can get you into trouble with Medicare. These “known unknowns” – requirements you know about but might make mistakes with – can sometimes lead to over-payments.

But, unlike in years past, you cannot simply gloss over these errors, he said.

“You can no longer simply fix something, sweep it under the rug, and not worry about it. That’s the way it has been for decades,” he said. “Now, the rule is if you see something you’ve done wrong, you need to identify and quantify it, fix it, and re-pay it.”

Now, when over-payments occur, Medicare requires you to document your efforts to identify the payment error and payback the reimbursement within 60 days of becoming aware of the problem. And, they expect you to launch the repayment process no more than six months after you notice the over-payment.

In an effort to help you avoid these repayment issues in the first place, Davis offered guidance in nine areas.

 and actively avoid referrals to facilities where you or an immediate family member have a financial interest. Each violation carries up to a $15,000 fine for each person who is involved who should have known the referral was problematic, Davis said, and it could result in your being excluded from all federally-funded healthcare programs.

To potentially avoid this problem in an imaging center, establish a protocol that does not allow referrals from family members, and require all radiologists in your practice to provide an update on all professional changes for their family members at least annually. Hospital-based radiology groups have two options, he said. Studies can be farmed out to independent contractors or a non-related radiologist in the group can bill for the service in his or her individual name.

The rules around teleradiology have evolved over time, Davis said. To be compliant, remember that you must be licensed in the state where your patient underwent the technical component of his or her diagnostic procedure, and you cannot bill Medicare for professional services rendered outside of the United States. Also, be careful to bill the correct Medicare-approved contractor for services provided.

Davis also pointed out that the current Medicare practice that allows for the billing of official reads after wet reads have been completed could be changing.

When you bill for the professional component of services, be sure you provide a full interpretation that fulfills the requirements under Medicare or any other payers, Davis explained.

Radiology Assistants and Radiology Physician Assistants

Radiology assistants (RAs) and radiology physician assistants (RPAs) are not considered to be the same as physicians assistants or nurse practitioners. They are not recognized as Medicare Part B suppliers, he said, and you cannot bill for them the same way as you would the other healthcare professionals.

When analyzing how their services were provided, distinguish between the setting. In a hospital, a radiology group cannot bill for any imaging service an RA or RPA performs as a physician service. If you bill for any role they play as if the supervising physician has performed the task, it creates a compliance problem, he said.

In the office setting, though, Medicare will pay for any non-diagnostic services your RA or RPA provides if they are incident to the physician service. For example, these services must be integral to the physician’s professional services and must commonly be billed without charge or included in the physician’s bill. It also must be a service commonly rendered in a physician’s office and must be completed under direct supervision. It is important to note that it is not necessary for the physician to be in the same room – only in the same suite, Davis explained.

Medicare does not allow you to amend, change, or add to any radiology report for the sole purpose of securing a higher reimbursement rate, he said. Doing so could constitute Medicare fraud, exposing you to the False Claims Act that carries penalties or criminal prosecution.

Overall, you should complete medical documentation at the time you see the patient, but Medicare does provide a little wiggle room. If you need to fully complete documentation with information that was not available at the time of care, you can do so shortly after rendering services. But, these instances should be limited and should not be how you normally handle patient medical documentation.

When performing diagnostic tests or procedures, double-check to be sure all services have been explicitly ordered in writing by the patient’s referring physician and that the order directly points to the basis for the test. Any tests not specifically ordered are not considered reasonable or necessary under Medicare.

Supervising physicians at independent diagnostic testing facilities must also obtain a written order from the treating physician before adding any addition procedures, Davis explained. That includes selecting a more clinically appropriate test, as well as adding a subsequent test if initial results are normal or if more information is needed. Be sure to include the validating reasons for any additional tests in your written report.

For Medicare-approved contractors, the supervising provider must be a physician and most likely must be a radiologist, Davis said. Physician assistants and nurse practitioners cannot be supervising providers.

All electronic orders must indicate that they have been electronically signed by a specific provider. Without that disclaimer, the order is not valid.

And, although this is not required, Davis recommended that imaging centers keep a signature log if they receive unrecognizable or illegible signatures.

Radiologists must provide their provider transaction access number (PTAN) for any services they render. A non-radiologist imaging center owner cannot use his or her PTAN to bill for professional services.

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Paying attention to these requirements and regulations can help you avoid Medicare over-payments and any potential suggestions of fraud.

9 Compliance Pitfalls to Avoid

Nearly 70 percent of all radiology practices have applied for financial relief during the COVID-19 pandemic – a statistic that highlights on the significant toll this outbreak has taken on the industry overall.

 officials from the American College of Radiology (ACR) and Radiology Business Management Association (RBMA) published the results of a survey of more than 200 radiology practices from across the nation.

According to the survey responses, more than 90 percent of imaging centers, hospital-based programs, mixed practices, and breast centers that applied for stimulus funds or loans actually ended up applying to two or more program for financial relief. And, as the pandemic lingers on and patients continue to forego diagnostic imaging services, ACR and RBMA leaders worry that the $175 billion in emergency funds provided by the Coronavirus Aid, Relief, and Economic Security (CARES) Act and the Paycheck Protection Program and Health Care Enhancement Act will fall short of industry needs.

“It remains uncertain whether this level of funding would be adequate or additional congressional action may be necessary to stabilize healthcare markets,” wrote the team, led by Ajay Malhorta, M.D., associate professor of radiology and biomedical imaging at Yale University School of Medicine.

The ACR and RBMA reached this determination by gathering member responses to a 48-question survey delivered via email in May. They collected data, focusing on April, on patient demographics, volumes, financials, staff and personnel changes, and recovery potential. They received 228 responses from 80 hospital-based practices, 64 mixed practices, 26 imaging centers, three other centers, and one breast center.

Based on their analysis, the investigators found almost all practices experienced significant volume reductions during April, ranging from 56.4 percent to 63.7 percent. Outpatient volumes dropped between 55 percent and 60 percent, and emergency imaging fell roughly 40 percent during the first week of hospitalizations.

Most practices reported that they had existing teleradiology capabilities prior to the pandemic, and 22.3 percent said they launched this type of set-up once the outbreak become apparent. Even with the increase in remote reading, though, roughly 15 percent of radiologists said they tested positive for COVID-19. Among respondents, 52.3 percent said they had inadequate access to personal protective equipment (PPE), while 35.3 percent said their PPE supply was not an issue.

Despite the deep cuts to imaging volume over the past several months, though, the survey response point to optimism with between 62 percent and 88 percent of radiologists anticipating at least some type of volume recovery. Between 52 percent and 64 percent said they expected a near-term surge as elective imaging begins to open up.

Malhotra’s team said they plan to re-assess this situation again as the pandemic continues to progress, noting that the near future remains nebulous.

“The survey shows the dramatic impact of the COVID-19 pandemic on radiology practices and the response measures taken during the crisis,” they said. “The continued spread in parts of the U.S. and possibility of further increases in parts previously affected adversely make prediction of the short- to medium-term impact unclear. These survey results will hopefully help the radiology leadership gauge the initial impact and make appropriate changes in response to the pandemic.”

More than 90 percent of practices applying for assistance submitted to two or more programs.


Radiology Practices Seeking Pandemic Financial Aid Nears 70 Percent

Three of the nation’s leading medical imaging organizations announced Wednesday that they are joining forces to create a new Medical Imaging and Data Resource Center (MIDRC) to support efforts to better understand, diagnose, monitor, and treat patients with COVID-19.

Together, the Radiological Society of North America (RSNA), the American College of Radiology (ACR), and the American Association of Physicists in Medicine (AAPM) will work – with funding from the National Institute of Biomedical Imaging and Bioengineering (NIBIB) – to create an open-source database with medical images from tens of thousands of patients who have tested positive for the virus. MIDRC will be hosted through the University of Chicago via a contract with Maryellen Giger, Ph.D., NIBIB MIDRC principal investigator and chair of the AAPM Data Science Committee.

ACR Set to Coordinate Image Collection for COVID-19 Study

“The MIDRC database will provide a critical tool to help the medical imaging community, doctors, and scientist better understand COVID-19 and its biological effects on humans,” said Etta Pisano, M.D., ACR chief research officer. “This knowledge, and the technological advancements the registry can enable, will ultimately help providers save lives.”

Medical imaging has been invaluable during the pandemic in helping providers detect, diagnose, and manage the disease, but artificial intelligence (AI) algorithms could help radiologists more effectively triage and interpret scans. The MIDRC is designed to collect and annotate the thousands of images needed to train these algorithms, giving engineers, physicians, and scientists the opportunity to analyze and organize the data in ways that can help answer critical questions.

RSNA Launches Own Open COVID-19 Medical Images Database

According to the three-institution team, the MIDRC will include more than 10,000 chest CT scans and X-ray images from COVID-19-positive patients. Many images will be culled from the ACR COVID-19 Imaging Research Registry and the RSNA International COVID-19 Open Radiology Database (RICORD), and researchers worldwide will have access to them to answer clinical and logistical questions.

“Access to this unprecedented resource will soon fuel expedited AI research to provide better diagnosis, new treatments and more effective monitoring to guard against COVID-19 resurgence,” Giger said. “This is a significant step in the effort against COVID-19.”

MIDRC will include five infrastructure development projects, will oversee 12 research projects, and will include roughly 20 university labs. The focus will initially be on COVID-19, but the coordinators said it will eventually expand to work against other diseases.

Medical imaging and data center will support development of artificial intelligence and medical advancements during the pandemic.


RSNA, ACR, AAPM Join Forces in COVID-19 Image Database for AI

Siemens Healthineers announced Wednesday it has secured 510(k) clearance from the U.S. Food & Drug Administration (FDA) for its mobile head CT scanner SOMATOM On.site.

The system is designed to provide head imaging for critically patients without needing to transport them outside of the intensive care unit. Doing so eliminates both the risk and the cost of moving a patient to the radiology department, company officials said.

“The SOMATOM On.site transforms the delivery of care for critically ill patients who require a CT head scan,” said Douglas Ryan, vice president of computed tomography at Siemens Healthineers North America. “Bedside imaging helps to reduce patient transports, thereby reducing the risk of infection while improving workforce efficiency.”

According to company information, SOMATOM On.site can provide consistent patient positioning in the scanner through easy scan set-up, fast workflow, and integrated patient support accessories. The user interface – myExam Companion – assists the technologist with system navigation to ensure consistent results, and an integrated camera allows for easy maneuvering with real-time viewing on the built-in Touch UI display.

In addition, company officials said, the scanners telescopic gantry enables the technologist to move the radiation source away from the patient during scanning while the rest of the machine stays in place. And, based on company data, the telescopic, self-shielded gantry design with attachable front and back radiation shields reduces scatter radiation and provides radiation protection for neighboring patients and staff.

U.S. Food & Drug Administration grants 510(k) clearance for SOMATOM On.site.


Siemens Healthineers Captures FDA Clearance for Bedside Head CT

Imagine reclaiming nearly an hour of your time every day – taking fewer phone calls and spending less time on administrative tasks. A radiology concierge service can make that dream a reality.

This type of service can streamline your workflow and reduce your stress, said Reed Humphrey, vice president of technology consulting at healthcare technology company Canopy Partners. He outlined the benefits of launching such a service, as well as how to design one, during an Aug. 4 session of the Radiology Business Management Association 

“These services help improve the quality of care within the technologists, the referring physician community, and the patients by getting the right study to the right radiologist at the right time,” he said.

Overall, concierge centers field telephone calls and handle administrative tasks, freeing radiologists up to focus on the more heavy-lifting image interpretation without distractions. On average, Humphrey said, they can boost productivity between 5 percent and 10 percent while bolstering your patient and referring provider satisfaction scores.

Effective concierge strategies have both a personal and technical component, said Humphrey’s co-presenter Laurie Shoaf, Canopy Partners radiology concierge services manager. The keystone is the professional radiology assistant (PRA). This cadre of trained staff assumes responsibility for the communication and administrative tasks radiologists currently juggle.

Overall, they support a radiology practice in four ways. They can directly communicate findings to referring providers or connect radiologists and ordering physicians to discuss more critical cases, and they can escalate urgent images, such as potential strokes, to ensure timely reads. In addition, PRAs can identify and fix order errors, such as requesting missing information or images, and they can handle all inbound calls, facilitating provider consultations and protocol questions.

On the technical side, Humphrey said, you will need scheduling software, communication tracking, and instant messaging for in-the-moment referring provider feedback. But, two system features are responsible for most of the efficiency – the smart worklist and a streamlined phone system.

The smart worklist, which can lead to a 10-percent to 15-percent efficiency improvement, lets you see all information in one place at one time, and it can help balance the workload between your radiologists, as well as funnel sub-specialty reads to the most appropriate provider. In some cases, Humphrey said, Canopy Partner’s clients have experienced a more than 35-minute improvement in turnaround times across emergency, outpatient, and inpatient scans.

Implementing a simplified phone system that includes a single phone number for the practice and a database of all referring provider phone numbers can make workflow easier. The best practice, Shoaf said, is to publish the phone number internally and externally to ensure PRAs can connect technologists and referring providers with the most appropriate radiologists quickly.

“It minimizes unwanted calls and disruptions in the reading room and provides the ability to triage those calls from a variety of sources to ensure timely turnaround,” she said. “And, radiologists no longer have to give out their personal cell phone numbers.”

North Carolina-based Cone Health and its diagnostic imaging partner Greensboro Radiology have experienced significant improvements with a radiology concierge service, Humphrey said. Currently, Greensboro Radiology’s 75 providers are responsible for reading the more than 700,000 images that come from the health system each year.

According to their analysis, he said, the PRAs field nearly 83,000 phone calls annually, totally approximately 178,000 minutes of fielding questions and processing requests. Doing so has alleviated 2,970 hours of administrative time for the radiologists. Averaged out, he said, it equates to a time savings of 39 minutes per 9-hour shift. In terms of productivity time, having the PRAs has added 313 radiology shifts to the practice – that is similar to have an additional 1.56 radiologists available for reading and interpretation.

There are several things to consider if you want to launch a radiology concierge service for your practice, Humphrey said. To be sure you cover all your bases, he suggested following this check list:

License and install all the needed software for your smart worklist and hardware for any new workstations

Determine hours of operation for the service (weekdays, weekends, nights, 24/7, etc.)

Build a knowledge database for PRAs, including radiologist, referring physician, and technologist contact information; radiologist subspecialties, schedules, and preferences; and technologist locations and modalities

And, above all, he said, test the service extensively before you officially launch it.

If you have these pieces in place, he said, you will create a service that can set you and your colleagues up for the greatest level of success.

“These programs free up the radiologist to focus on practicing at the top of their license,” he said. “Radiologists should always be asking themselves, ‘What is the best use of my time right now?’ Radiology concierge programs help them to focus on that.”

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Implementing a radiology concierge service can alleviate the administrative tasks that can de-rail your image interpretation time.


RBMA: Reclaim Your Time with a Concierge Service

The American College of Radiology (ACR) announced this week its Center for Research and Innovation (CRI) will spearhead the imaging coordination for a multi-institutional study focusing on patients who have severe, acute COVID-19 infection.

ACR will collaborate with Oregon Health & Science University (OHSU) for this endeavor that is funded by the National Institutes of Health National Heart, Lung, and Blood Institute.

This initiative, called the COVID-19 Observational Study (CORAL) is part of a national hospital network known as Prevention & Early Treatment of Acute Lung Injury (PETAL) Network and will bring together clinical and imaging data, as well as outcomes for patients who have severe infections. The goal is to support and inform epidemiology and resource utilization.

“We at the ACR are pleased and proud to be part of the effort by our colleagues who are caring for patients suffering with COVID-19 who require hospital care,” said Etta Pisano, M.D., ACR chief research officer. “We hope the collection of imaging and clinical data that the PETAL project creates will lead to improved treatment and diagnosis of COVID-19 complications, including advanced lung disease, stroke, and cardiac dysfunction.”

To make this impact, ACR officials said, the study has a three-pronged approach. First, it will establish a registry. Second, individuals involved will design a cohort of biospecimen collection, clinical phenotyping, and outcomes. And, lastly, they will assess health systems.

The ACR CRI is responsible for collecting imaging exams from registry enrollees and identifying associations between those images and clinical data. These images will be archived and will be available to other researchers after the study has finished.

In collaboration with Oregon Health & Science University, the American College of Radiology will gather images for a multi-center study focusing on patients with severe, acute viral infection.

Radiology has been anticipating the full implementation of Appropriate Use Criteria (AUC) and clinical decision support (CDS) since 2014 with the Protecting Access to Medicare Act, and it finally appears the industry could finally be seeing light at the end of the tunnel. So, it is now more critical than ever to be familiar with the next steps and implementation process.

In an Aug. 3 session during the Radiology Business Management Association (RBMA) PaRADigm Shift 2020 virtual conference, industry coding and reimbursement expert Melody Mulaik, MSHS, FAHRA CRA, RCC, CPC, CPC-H president of Revenue Cycle Coding Strategies, LLC, outlined how radiologists can prepare for full AUC and CDS implementation and what remaining challenges could be out there.

“At this point, we really should be pretty far along in the implementation process, and hopefully, you are working through some of the finer points and the implementation of the details related to this process,” she said. “But, I want to remind you as you’re working with people who are implementing these things, they don’t have the level of understanding around the guidelines that you do. While we’ve been talking about this in the imaging world for many years, for a lot of organizations, this is the first year they’re talking about this now that the deadline is looming.”

Compliance is important, she added, because the Centers for Medicare & Medicaid Services (CMS) will refer to AUC and CDS use to identify the top 5 percent of providers who most frequently order inappropriate imaging. CMS will, then, require prior authorization for any advanced imaging services ordered by those outlier providers.

After several years of delays, the Centers for Medicare & Medicare Services (CMS) determined 2020 would be a testing year, confirming they would process payment whether an AUC consultation supported imaging. Currently, the industry is planning for full implementation on Jan. 1, 2021, with the expectation that payments will be denied if AUC protocols are not followed properly.

But, that start date is not set in stone, Mulaik said. CMS has not yet released its Proposed Rule, meaning the Final Rule is not likely until December of this year. The hope, she explained, is that mandatory implementation will be delayed for at least another six months to one year to allow all clinical environments to fully comply.

And, those compliance requirements remain the same. Referring providers must consult AUC when ordering imaging for outpatients and individuals in observation, and they must relay the consultation results to the radiologist directly. Radiologists must also comply with the regulations. Exemptions can be made for inpatient scans, emergency studies that fall under EMTALA, critical access hospitals, and providers who have a hardship, such as an internet outage. Published CMS 

 offers more specific details for a variety of situations.

Once it is fully implemented, AUC will initially focus on at least eight priority clinical areas – coronary artery disease, suspected pulmonary embolism, headache, hip pain, low back pain, cervical or neck pain, shoulder pain, and lung cancer. Remember, though, that AUC applies to all advanced imaging – not just these eight areas.

Remember that CDS use is required for claims submitted with Medicare as the primary insurance. But, do not forget claims where Medicare is listed as the secondary payer, as well. Mulaik recommended beginning to test claims with commercial payers now to work through any obstacles or glitches before the implementation deadline.

To be in full compliance on Jan. 1, 2021, Mulaik advised submitting claims to CMS that include one G-1011 code per mechanism and attaching modifiers at the CPT code level to indicate AUC adherence. Referring providers or their direct clinical staff must report the codes – if facility staff do it, it is a compliance violation, she said.

 CDS consult not required because the patient has suspected or confirmed emergency medical condition

 CDS consult not required due to insufficient internet access hardship exception

 CDS consult not required due to electronic health record or CDS mechanism vendor issue hardship exception

 CDS consult not required due to extreme and uncontrollable circumstances hardship exception

 Ordered service does not have AUC in the CDS mechanism

 Unknown if referring provider consulted CDS for ordered service

Although it has not been announced, it is possible the -MH modifier will disappear once full implementation is enacted, Mulaik advised. If you submit a claim with it after Jan. 1, 2021, it is likely your claim will be denied because CMS will no longer accept that you do not know whether your referring providers are using CDS.

CMS has also not yet provided clarity about what modifier radiologists should use if the technical component of a service was performed in a non-applicable setting, such as a critical access hospital. It is possible CMS could provide another modifier to indicate this situation, she added.

As a radiologist, the long-standing challenge with AUC has been the lack of control you have over whether referring providers correctly complete the process. With AUC being intergrated into the electronic health record, this will become less of a concern with hospital-based referring providers. Still, Mulaik said, ensuring compliance with community-based, non-hospital employed physicians could be an ongoing obstacle. When possible, identify who the gatekeeper is in those practices to ensure the AUC compliance process is observed and completed correctly.

In addition, possible code denials and slow adoption from providers can also be stumbling blocks. Begin testing now before implementation is mandatory so you can flush out any potential problems and figure out workable solutions.

But, there are ways you can keep tabs on AUC performance, she said. Reviewing this information can let you know where additional work is needed. She suggested these metrics as good indicators for AUC compliance:

Examining utilization by provider and practice both pre- and post-implementation.

Analyzing CDS mechanism scores by providers.

Evaluating primary and secondary payer denials, distinguishing between AUC and medical necessity rejections.

Identifying any missing AUC information by provider and facility staff to determine where omissions occur most frequently.

Segment out AUC compliance by modality when appropriate.

Ultimately, Mulaik said, it is critical that you continue to impress upon your referring providers that they should be developing the AUC and CDS habit now. Even as more guidance from CMS is forthcoming and the proposed and final rules are yet to be published, working through any pain points now with coding errors and denials could pave the way for smoother reimbursement for services rendered once full implementation is in place.

Coding and reimbursement expert Melody Mulaik offers insights about what the industry should do to fully prepare for the likely mandatory implementation of appropriate use criteria and clinical decision support. 

RBMA: What You Need to Know About Looming Appropriate Use Criteria Implementation

In emergency rooms nationwide, the use of diagnostic imaging is on the rise with pediatric patients, a new study shows.

Between 2009 and 2018, a study published Aug. 3 in 

 reveals, emergency providers ordered more MRI scans and ultrasounds for pediatric patients. But, the amount of CT scans requested fell.

By examining records from more than 26 million emergency department visits from Jan. 1, 2009, to Dec. 31, 2018, a team from the University of Pittsburgh Medical Center, led by Jennifer Marin, M.D., MSc, associate professor of pediatrics and emergency medicine, calculated the change in ordering rates for ultrasounds, MRIs, and CTs. The data came from the Pediatric Health Information System administrative database.

They found only CT use decreased during the study time frame. And, it was variable based upon location and other diagnostic strategies used.

“The magnitude of the decrease in CT use varied by site and was associated, in part, with the use of alternative advanced imaging modalities for certain diagnoses, most notably ultrasonography for abdominal conditions,” the team wrote.

, pediatric and emergency medicine providers Alan Schroeder, M.D., and Daniel Imler, M.D., from Stanford University School of Medicine, noted that while the reduced radiation exposure from CT in children falls in line with the Image Gently campaign and is encouraging, the overall exposure of pediatric patients to advanced imaging is still not optimal.

Pediatric Emergency Department Imaging Use Changes

Overall, in this study, the drop in CT use can be attributed to decreases in eight areas: concussion (23-percent drop); appendectomy (14.9-percent drop); ventricular shunt procedures (13.3-percent drop); migraine and other headaches (12.4-percent drop); nervous system disorders (10.1-percent drop); abdominal pain (6.1-percent drop); ear, nose, mouth, throat, cranial, facial diagnoses (5.9-percent drop); and seizure (5.3-perent drop).

For abdominal pain, the investigators found that the implementation rate of abdominal ultrasound surpassed the accompanying reduction in abdominal CT scans, pointing to a potential overuse of ultrasound.

While the length-of-stay in the emergency department did not change and hospitalizations and 3-day re-visit rates decreased during the study time frame, the team did find significant variations in imaging use in emergency departments nationwide. Specifically, use varied for ultrasound for appendectomy (median 57.5 percent), MRI (median 15.8 percent), and CT for ventricular shunt procedures (median 69.5 percent).

According to Schroeder and Imler, the higher use of imaging for patients who were ultimately hospitalized indicated that more imaging use does not necessarily result in reduced hospitalization.

Emergency providers are utilizing more ultrasound and MRI scans, fewer CTs.


Pediatric Imaging Use in Emergency Department on the Rise

Massachusetts General Hospital has designed an intervention that can effectively improve screening mammography rates, particularly among women who are in racial and ethnic minority groups.

Falling in line with the pink ribbon for breast cancer awareness, the hospital launched its Pink Card program in November 2016. As part of the pilot initiative, during scheduled visits, participating doctors distributed pre-printed mammogram reminder cards that could be redeemed for a same-day, walk-in screening appointment at one of three area locations.

Investigators published the results of the intervention recently in the 

“By offering walk-in screening examinations that coincide with physician office visits in the same building, this program removes the need for additional dedicated screening visits,” said the team, led by Gary X. Wang, M.D., Ph.D., radiology instructor. “In turn, this can reduce difficulties that arise from transportation, challenges, competing priorities, including other personal healthcare needs and caregiver responsibilities, and financial burdens incurred by taking time off work, barriers commonly encountered by racial and ethnic minorities.”

In fact, this intervention was specifically designed to help address the obstacles many women in racial and ethnic minority groups face when it comes to getting the breast cancer screening they need. That is why, the team said, they launched the program in one of their outpatient community breast imaging facilities in the Boston suburbs.

During the study period, 3,688 women receive Pink Cards from their primary care or obstetrician-gynecologists that included the location and hours of operation for on-site imaging centers. Of the group, 19.9 percent used their cards. The women who redeemed their cards were less likely to be up-to-date with their biennial screening mammogram, and they were also more likely to be younger, Asian or black, and speak English as a second language.

Not every patient seen in the clinic received a Pink Card – providers used their own discretion to distribute them. According to the team, the clinics reserved up to four appointment slots daily for these walk-in patients, and mammograms where performed typically within 30 minutes of the patient’s arrival.

Overall, Wang’s team said, the use of their program pointed to the continued need to address health disparities that prevent many women in racial and ethnic groups from getting the breast cancer screening services they need – and the results indicate that such an intervention can be implemented in other off-site centers and practices.

“The Pink Card program offers the potential to enhance mammography screening access and engagement,” they said, “especially among vulnerable populations.”

Provider-distributed cards facilitate same-day mammogram screenings for women in racial and ethnic minority groups.

Pink Cards Secure Same-Day, Walk-In Mammograms 

CT scans have revealed a link between weight and brain function – the more a patient weighs, the higher their levels of brain dysfunction.

 investigators from Amen Clinics discussed the link between body mass index (BMI) and areas of the brain that are most vulnerable to Alzheimer’s damage. With 72 percent of Americans falling into the overweight or obese categories, these findings could have a far-reaching impact.

“This study shows that being overweight or obese seriously impacts brain activity and increases the risk of Alzheimer’s disease, as well as many other psychiatric and cognitive conditions,” said lead study author Daniel G. Amen, M.D., Amen Clinics founder.

For this study, researchers from Amen Clinics, a network of outpatient mental health clinics nationwide, analyzed more than 35,000 functional neuroimaging scans using single-photo emission CT (SPECT) from more than 17,000 individuals ages 18 to 94, measuring blood flow and brain activity. This study is the largest to link obesity with brain function, they said.

Based on their study results, Amen’s team determined that blood flow – the No. 1 brain imaging predictor of the likelihood of Alzheimer’s development – progressively decreased as a person’s weight increased. This phenomenon was seen in brain areas that can be most affected by Alzheimer’s – the temporal and parietal lobes, hippocampus, posterior cingulate gyrus, and precuneus -- they said. These findings were the same during cognitive tests, as well as while patients remained still.

These CT findings bolster the growing perception of Alzheimer’s as a lifestyle disease, said Geroge Perry, Ph.D., chair of neurobiology at the University of Texas at San Antonio. By showing how obesity alters blood supply to the brain, promoting Alzheimer’s, he said, these results are a “major advance” in helping patients understand that lifestyle changes can help prevent Alzheimer’s.

Amen agreed with Perry’s assessment that these findings can be clinically impactful.

“One of the most important lessons we have learned through 30 years of performing functional brain imaging studies is that brains can be improved when you put them in a healing environment by adopting brain-healthy habits,” he said, “such as a health calorie-smart diet and regular exercise.”

Brain imaging shows blood flow to the brain progressively reduces as a person’s weight increases, promoting the development of Alzheimer's.

SPECT Scan Reveal Link Between Obesity, Brain Blood Flow, and Alzheimer’s

Country of residence could play a significant role in whether digital breast tomosynthesis (DBT) is considered more effective in breast cancer screening than digital mammography (DM). And, there is also a price tag associated with that tipping point in efficacy, a new study has revealed.

 investigators from The Netherlands detailed their research with a simulated population of women. Through their endeavors, which ran from March 2018 to February 2019, they generated 10,000 outcomes.

They determined that DBT could be considered cost-effective at a willingness-to-pay threshold of $38,500 per life-year gained, but not at $22,000. In addition, they found countries with higher breast imaging recall rates, such as the United States, were more likely to experience DBT’s benefits. Nations, such as The Netherlands, where recall rates are low and mammography compliance is high are less likely to consider DBT as a cost-effective option.

“With current data, biennial DBT screening between 50 and 74 years of age is not expected to be cost effective at the Dutch willingness-to-pay threshold of [$22,000] per life year gained and 3.5-percent annual discounting,” wrote the team, led by Valérie Sankatsing, Ph.D. candidate and researcher with the Erasmus department of public health.

For this study, Sankatsing’s team used a micro-simulation model to create 10,000 model runs with a simulated group of 1 million women per run. According to the team, the women were born in 1970 and underwent biennial screening between ages 50 and 74, and the team assigned half the women to DBT and half to DM.

During the study, the team applied the actual screening compliance rate from The Netherlands of 80 percent to the simulated cohort. For DBT, they estimated it bolstered sensitivity by 18 percent, had a 30-percent positive predictive value, and cost $100 more than DM. 

Each of the 10,000 model runs created an incremental cost-effective DBT-DM pair, and their analysis determined DBT is both the more effective and expensive screening option. According to the data analysis, per 1,000 women, DBT provided a 7-percent rise – 13 years – in life-years gained, prevented 6-percent additional deaths from breast cancer, and resulted in 2.5-percent drop in false positives. But, it did cost more than DM with a mean lifetime cost of $151,311.

To determine whether DBT was truly cost-effective, the team said, they examined the willingness-to-pay threshold. The lower the threshold, the lower the cost-effectiveness, they said. For a willingness-to-pay threshold of $22,000, DBT was only deemed cost-effective in 36 percent of cases, but when the threshold rose to $38,500, it was considered cost-effective in 66 percent of situations.

This difference among thresholds, they said, underscores the likelihood that countries with lower recall rates may not turn to DBT as much as a viable screening option.

“A meta-analysis evaluating recall rates with DBT compared with DM showed that the reductions in recall rates were prominently found in studies from the United States that reported high baseline recall,” Sankatsing’s team wrote. “The decrease in recall rates and the number of false-positive results with DBT, thus, depends on the initial recall rate.”

Nations with lower breast imaging recall rates and high mammography compliance are less likely to view digital breast tomosynthesis as a cost-effective screening option.
