H.A. Abella

A Centers for Medicare and Medicaid Services proposal meant to streamline billing and other imaging management duties could actually backfire and create administrative havoc, according to radiology administrators.

The decision detailed in CMS's Transmittal 1823, issued Oct. 2, requires physicians and hospital administrators to disclose separately the place and date of service using new codes for the professional and technical components of imaging exams.

Medicare says the codes should reflect the actual place where each service was provided. Hospitals customarily bill based on where the examination occurred, not where the interpretation took place. Because the events usually take place at different locations and times, the new rules will mostly affect providers of imaging services by increasing paperwork and overhead costs, said Michael R. Mabry, executive director of the Radiology Business Management Association.

“It is really hard to figure out what the reimbursement impact would be from these changes,” Mabry said. “But we do know that it is going to change the way we practice and store information.”

Language in the transmittal suggests CMS harbored concerns that many physicians were misusing current place code 11. CMS tried to address this issue, but-largely by accident rather than design-it has issued guidelines that run counter to the way practices currently operate, Mabry said.

“In an attempt to help, CMS has potentially made the situation worse,” he said.

Responding to a request from the RBMA, the American College of Radiology, the Association for Medical Imaging Management, the Healthcare Billing and Management Association, and the Medical Group Management Association to delay implementation, CMS in December rescinded Transmittal 1823, replacing it with Transmittal 1873. The new document enforces the place of service requirement as of Jan. 4, but delays implementation of the date of service requirement until July.

The group had acknowledged the agency's move was well-intentioned, but worried the proposed reporting rules could confuse providers and lead to unforeseen adverse consequences.

“There is major confusion over the place of service transmittal. So far, Medicare administrative contractors are reported anecdotally to be telling radiologists not to change their billing practices,” said Thomas Greeson, a healthcare attorney with the law firm of Reed Smith in Falls Church, VA. “RBMA has crafted a questionnaire to aid business managers seeking guidance from Medicare carriers on how to respond to the transmittal.”

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Guidelines set admins scrambling

A study by U.S. and Egyptian researchers has challenged the conventional wisdom regarding cardiovascular disease. Using CT, the investigators found evidence that, unlike other chronic conditions that plague affluent postindustrial Western societies, atherosclerosis has been around since at least the time of the ancient pharaohs.

“Some of the patients I have mentioned the study to have had a certain sense of relief,” lead investigator Dr. Randall Thompson told 

. “They were blaming themselves for having had a heart attack and were happy to learn that the disease has been around since the time of Moses.”

Thompson and colleagues sought evidence of arterial disease in individuals who lived three millennia or longer ago. They performed whole-body multislice CT scans on 22 mummies preserved in the Egyptian National Museum of Antiquities in Cairo. The investigators found evidence of atherosclerosis of the abdominal or thoracic aorta or peripheral arteries in nine of 16 mummies with visible cardiovascular tissue. This included seven subjects who were 45 or older and two who were younger than 45 when they died. Findings appeared in the Nov. 18 issue of the 

Journal of the American Medical Association.

The study lacks a direct pathological correlation and the power to explain the prevalence or severity of atherosclerosis in the distant past. However, it does provide proof that ancient Egyptians belonging to the upper social strata who were middle-aged or older already faced a genetic and environmental predisposition to develop the condition, said Thompson, a cardiologist at St. Luke's Hospital's Mid America Heart Institute in Kansas City, MO.

“The findings challenge the concept that this is primarily a disease of Western lifestyles,” he said.

A study by U.S. and Egyptian researchers has challenged the conventional wisdom regarding cardiovascular disease.

Atherosclerosis thrived in antiquity, mummy scans show

RSNA president Dr. Gary J. Becker opened with a sports quotation. “Today we are going to learn how to put on our socks and lace our shoes.” With that he exhorted attendees at the opening session to join a drive for quality in radiology that could bolster the specialty in the face of the challenges that are to come.

The phrase, spoken by legendary college basketball coach John Robert Wooden, was a reference to what lies ahead for radiologists, Becker said. Wooden revisited these fundamentals before sending out to the court any of the teams that won him a record 10 National Collegiate Athletic Association titles. Sock wrinkles inside improperly laced shoes could turn to blisters that would keep the young stars from practicing and, ultimately, from shining. Wooden believed such minutiae could affect a team's ability to win and thus required a focus on quality improvement starting from the very first day of practice.

“Today we radiologists find ourselves in a similar situation. One of the most vital priorities for our profession is the adoption of a new focus on quality improvement,” Becker said. “I believe quality and our commitment to it will be a key factor in determining our future.”

Issues such as disregarding quality improvement principles, holding on to preconceived notions and attitudes, and the lack of a culture of improvement could wreak havoc in the field unless radiologists acknowledge and deal with them soon, Becker said. If radiologists choose to ignore them, they do so at their own risk because the demand for individual transparency and accountability from patients, families, and public and private healthcare organizations is only going to grow.

“All this means we are going to need to increase our focus on safety, quality, performance measurement and improvement, and value,” he said.

According to Becker, the most efficient care, and the end to a culture of preventable medical error, waste, and service fragmentation, will depend to a significant degree on the implementation of quantitative imaging and informatics. Big gains in quality improvement can be achieved through the use of computerized radiology order entry and decision support systems and through the use of structured reporting and computer-aided diagnosis.

The quantitative potential of the latest imaging technologies will give radiologists a central role in the new age of personalized, preemptive, predictive, and participatory, or “P-4,” medicine, Becker said. He encouraged attendees to check the meeting program and other resources available through rsna.org for information on quality improvements.

A number of studies have shown that quality can be improved, but complacency can ultimately spoil any gains. Radiologists should strive for ways to effectively measure and maintain quality beyond economics in order to earn the public trust once again, Becker said.

“When price is the differentiator for quality, quality pays the price,” he said.

A scientific paper presented at the RSNA meeting provided an example of one of many quality issues plaguing radiology today. Researchers from Massachusetts General Hos-pital in Boston found the number of unidentified and uncorrected errors in radiology reports of spine MRIs is significantly higher than that of corrected errors.

The investigators reviewed more than two million radiology reports of spine MRIs performed at their institution from January 2006 through December 2007. They found 14 reports with addended errors, or errors identified after the report was signed, and 20 with errors that had never been identified until their review. They also found that, in 2006, it took between five and seven days to correct an error and nearly twice as long the following year. Almost half the errors occurring in all the reports were probably or definitely clinically important.

According to the researchers, radiologists should check for errors and encourage colleagues to correlate the level of radiological lesions with clinical complaints and images. One of the most important implications of the study, they said, is a potential role for software applications like natural language processing to identify errors at the time of dictation or final signoff.

Dr. Steven Swenson, director of qua-lity at the Mayo Clinic in Rochester, MN, and chair of the American College of Radiology's quality metrics committee, made his contribution to the topic with a presentation on patient-centered radiology. Swenson reminded his audience that Hippocrates set the bar high for physicians when he made patient care the centerpiece of the medical profession. But, as Swenson pointed out, the same demand offers radiologists hope.

“If we live that patient-centeredness, the risk of commoditization goes away,” Swenson said.

Swenson also shared the conclusions from a group of 14 academic deans and medical officers he joined in 2008. One of them was that academic medical centers could not be patient-centered because this role conflicted with their academic mission. Even if it did not, the research mission funded by big pharmaceutical and device manufacturing companies would, he said.

Radiology could meet the challenge by granting patients five wishes: the information to make a choice, the right exam, open communication, a fair cost, and a safe exam.

“A key part of improvement is starting with a baseline,” Swenson said. “If you don't know where you're at, you don't have an opportunity to improve.”

RSNA president Dr. Gary J. Becker opened with a sports quotation. “Today we are going to learn how to put on our socks and lace our shoes.”

RSNA chief calls 2009 quality theme future for radiology

Using functional magnetic resonance imaging, researchers in the U.K. have gained a better understanding of what goes on in the minds of patients who have sustained severe neurological damage.

According to investigators, fMRI could yield evidence that patients might be fully aware even when the clinical assessment suggests they are comatose.

Clinicians typically infer whether patients with brain injury are conscious based on their behavior. However, recent studies indicate that 40% of patients who seem behaviorally unresponsive are, in fact, in a minimally conscious state and are erroneously diagnosed as being vegetative.

Such mistakes could have huge medical, ethical, and even legal consequences if they lead to termination of lifesupporting therapies, said principal investigator Martin M. Monti, Ph.D., a research scientist for the U.K. Medical Research Council and Brain Sciences Unit, a University of Cambridge research partner institution.

Monti and colleagues enrolled 20 healthy volunteers and one minimally conscious patient diagnosed with anoxic brain injury in 2007. Subjects underwent imaging while instructed to listen to a sequence of words first and then count the number of times a key word was heard. All showed activation of neural areas governing target detection and working memory while performing the counting task. This suggests that even the minimally conscious patient could retain information over time and act upon it. It also shows that it is possible to tell if a patient is conscious or not, Monti said. The report was released online Oct. 8 in the journal 

“This use of fMRI can help us better diagnose patients and diminish the misdiagnosis rate by allowing us to detect consciousness beyond what is apparent,” Monti told 

Such questions as how to know if patients who suffer severe brain injury are conscious, or how to tell whether they can hear, see, and understand, haunt neuroscientists. If patients can blink an eye in response to a command, physicians know they must be conscious. Trouble begins when perfectly conscious patients cannot move or produce any behavioral sign to convey this fact. The study makes a fundamental contribution in this regard, Monti said.

“The clinical application is immediate: If a patient is aware, but unable to produce a motor sign to communicate her state of awareness, it may be possible to gain this knowledge just by looking at her brain response.”

H.A. Abella

Articles

Guidelines set admins scrambling

Atherosclerosis thrived in antiquity, mummy scans show

RSNA chief calls 2009 quality theme future for radiology

fMRI indicates cognition in unconscious patients