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Radiology Administrator's Compliance & Reimbursement Insider, April 2008

Radiology Administrator's Compliance and Reimbursement Insider, April 1, 2008

Inside:

Reduce risks of radiation in children’s CT scans

Exam offers benefits for radiology/IT professionals

Know the risks before meeting with compliance vendors

Reduce risks of radiation in children’s CT scans

In the past decade, patients’ exposure to medical radiation increased due to advancements in CT technology. Approximately 4 million pediatric CT scans were performed in 2006. Soon, medical imaging (with CT scans as the largest contributor) will approach or potentially exceed naturally occurring background radiation as the single largest source of radiation for humans.

There’s no doubt that CT scans save lives. But children are particularly susceptible to radiation received from imaging scans. Cumulative radiation exposure to their developing bodies could, over time, have adverse effects.

It’s important for your facility to adopt measures to ensure children’s safety, says Marilyn Goske, MD, chair of the Alliance for Radiation Safety in Pediatric Imaging at Cincinnati Children’s Hospital Medical Center.

There has been action to help children; earlier this year, prominent radiology groups launched the Image Gently campaign.

Associations included in the effort are the Society for Pediatric Radiology, the American College of Radiology (ACR), the American Society of Radiologic Technologists, and the American Association of Physicists in Medicine (AAPM), founding members of the Alliance for Radiation Safety in Pediatric Imaging.

The campaign Web site (www.imagegently.org) contains the most recent research and educational materials to help determine the appropriate radiation techniques for the imaging of children.

The campaign aspires to change the way children are imaged in the United States, using kid-size, rather than adult-sized, radiation doses.

“Children are not just smaller adults,” says -Goske. “Their bodies are different and require a different -approach to imaging.”

Children are more sensitive to radiation and have a lifetime to manifest biological changes.

The best available risk estimates suggest that pediatric CT will result in significantly increased lifetime radiation risk over adult CT because of the increased dose per milliampere-second and the increased lifetime risk per unit dose.

To help mitigate the potential hazards for children, implement the following at your facility:

Discuss current practices in reducing radiation. Increase awareness for the need to decrease radiation doses to children during CT scanning. Evaluate what measures you currently employ to protect children’s safety.

Awareness of risks and available information should empower you to improve patient safety, says -Goske.

Some hospitals have state-of-the art machines that -automatically adjust radiation dosages to child levels. If you don’t have these machines, you can still use your current machines and work with your medical physicist to adjust the dosage appropriately, she says.

Change your daily practices. Collaborate with your technologists, medical physicist, referring doctors, and parents. Consider creating a pledge to lower radiation doses in children. Ask medical physicists to monitor pediatric CT techniques and involve technologists to optimize scanning.

Significantly reduce, or child-size, the amount of radiation used. First, contact your medical physicist to review your adult CT protocols, says Keith Strauss, M.Sc., director of radiology physics and engineering at Children’s Hospital Boston. If you do not have a medical physicist, find one, says Strauss.

Visit the AAPM Web site at www.aapm.org to identify medical physicists in your geographical area. Ensure that your adult protocol delivers radiation doses within ACR recommendations.

Use the simple CT protocols on the Image Gently Web site to downsize the protocols for kids, says -Goske. Remember, more is not better. Adult size (kV) and mAs are not necessary for small bodies, she explains.

Possible adjustments in the tube current, the spacing of CT slices, and slice thickness could reduce the radiation exposure while maintaining diagnostic image quality, according to Image Gently reports. Because children are smaller, these adjustments are not likely to compromise image quality.

Don’t overscan.

Eliminate multiple scans when possible. Single phase scans are usually adequate, especially for children. Pre- and postcontrast and delayed CT scans rarely add additional information in children yet can double or triple the dose, says Goske. Consider removing multiphase scans from your daily protocols.

Scan only the indicated area. For example, if a patient has a possible dermoid on his or her ultrasound, there is rarely a need to scan the entire abdomen and pelvis. Child-size the scan and only scan the area required to obtain the necessary information, says Goske.

Scan only when necessary. In many cases, CT scans will be necessary to save lives. Work closely with referring physicians and parents to determine whether a CT scan is necessary. Radiologists should consider developing more well-defined approaches to selection of patients for CT. However, for situations in which the diagnostic yield of CT is expected to be low, alternative examinations should be considered.

Give parents notice about safe imaging. A simple patient/parent handout can improve understanding of potential risks so that parents can be partners in minimizing scans. In other words, parents will be less likely to insist on scans that physicians say aren’t mandatory if they know the risk.

Conversely, studies show that a handout won’t cause parents to refuse studies recommended by the referring physician. (Use our model handout below.)

Insider sources

Marilyn Goske, MD, chair of the Alliance for Radiation Safety in Pediatric Imaging, 3333 Burnet Avenue, Cincinnati, OH 45229, 513/636-4975; marilyn.goske@cchmc.org.

Keith Strauss, M.Sc., director of radiology physics and engineering, department of radiology, Children’s Hospital Boston, 300 Longwood Avenue, Boston, MA 02115, 617/908-7492; Keith.Strauss@childrens.harvard.edu.

Keep parents informed of the realities regarding CT scan risks

Use the following FAQs to help parents understand the risks associated with CT scans. Consider having these handouts available for parents.

Q: Is there an increased risk of cancer from medical radiation, especially CT scans?

A: Although no one can point to a single individual and say that their cancer was caused by medical radiation, there is evidence that exposures to radiation levels found during CT scans may slightly increase the risk of future cancer. The risk for developing cancer is debated and variable, and may be zero, but estimates also range from about one in 500 to one in 10,000 fatal cancers from a single CT scan.

This needs to be interpreted against the risk of developing cancer over one’s lifetime. The risk of developing cancer is about one in five during a lifetime, so the extra risk from CT is very small. 

Q: If my doctor orders a CT scan, should I let my child have it?

A: Like any medical test, the beneficial information gained from the test should outweigh the risk of having the test performed. 

CT is a very powerful and valuable imaging technique that can provide important and even life-saving information. However, sometimes, imaging tests such as ultrasound and MRI can provide the same information as CT but not expose your child to any radiation. You should ask your doctor and imaging provider whether these alternatives are appropriate for your child’s situation. 

If a CT is the best test, make sure that your imaging provider uses appropriate low-dose techniques to minimize radiation exposure during the test.

Q: How can I be sure that my imaging facility is using appropriate reduced radiation techniques?

A: Some facilities that perform CT scans on adults do not use radiation dose reduction techniques when scanning children. 

You won’t know unless you ask, and it is both reasonable and within your rights to do so.

Your imaging provider should be able to provide you with information about procedures to reduce radiation doses during CT (such as reducing CT tube output, performing single-phase scans, and reducing exposure to areas away from the clinical concern).

Parents should also ask whether:

• The facility has American College of Radiology accreditation
• The CT technologists are credentialed
• The person interpreting the studies is a board-certified radiologist or pediatric radiologist

Source: The Alliance for Radiation Safety in Pediatric Imaging and the Image Gently campaign.

Exam offers benefits for radiology/IT professionals

If your radiology department or imaging center is like many others, you’re still looking for a good IT or PACS professional.

The new American Board of Imaging Informatics (ABII) Professional Certification exam will help eliminate the confusion and improve PACS around the country, says ABII member Chuck Socia R.T(R)(CT)(QM)/
-CIIP, director of hospital systems at Empiric Systems in Morrisville, NC.

“This exam is the best thing to happen to PACS in 10–20 years,” says -Bobby Himel, BS, RT(R)(CT)
(MR), CIIP, PACS administrator at Baylor Regional Medical Center at Plano, TX, and a Society for Imaging Informatics in Medicine (SIIM) member who passed the pilot exam in June 2007.

Mission: To improve imaging standards

ABII has created and manages the Imaging Informatics Professional (IIP) certification program and awards the Certified Imaging Informatics Professional (CIIP) designation to qualified candidates. The SIIM and the American Registry of Radiologic Technologists founded the ABII in 2007 and created a pilot program the same year, says Caroline Wilson, public relations director for SIIM.

Essentially, imaging informatics merges the technological know-how of the information age with the intricate needs of ABII’s mission to enhance patient care, professionalism, and competence in imaging informatics.

Challenge: To establish a credential program

According to SIIM, the ABII IIP certification program provides a proper credential for IIPs to enhance professional development, stimulate career growth, and offer objective validation of IIP experience.

SIIM defines an IIP as an individual who applies his or her education and clinical and IT expertise to managing enterprisewide PACS and other digital medical imaging systems. The primary role of the IIP is to evaluate, analyze, implement, and render informed opinions about the delivery of healthcare using imaging informatics systems.

Why is the certification necessary? The practice of IIP administration predates any specialty organization, training program, or certification body, says Socia. IIPs enter the profession with a variety of educational backgrounds and practical experiences. Many IIPs have acquired knowledge and expertise from informal guidance or on-the-job training, he says.

Specific education is not a prerequisite to the practice of IIP administration, Socia explains.

Eventually, the certification should lead to the development of an undergraduate curriculum toward a bachelor’s degree.

The issues have affected the industry for the past 10 years, says Socia. There have been no qualifications for PACS professionals. Yet these professionals are critical to any hospital or operation and can make or break the imaging department, he says. There is a great need for a quality person and a real way to quantify qualifications, he adds.

This certification will become the standard within our diverse PACS field, says Himel.

In essence, this test represents the marriage between IT and radiology technologists (RT), he says. There has been much confusion between the RT certification and IT qualifications. One could think of the ABII as the issuer of the marriage license and SIIM as the marriage counselor, he says.

How to register for the examination

Applications are now open for the next IIP exam, scheduled for September.

Interested IIPs should visit www.abii.org for more information and to determine eligibility for the exam. Registration should begin in April.

For each exam, space is limited to the first 100 registrants.

How to prepare for the exam

There are no set curriculum or practice tests for the IIP exam because SIIM remains independent of exam certification since they are an education and training organization, says Wilson.

Success on the ABII IIP certification exam will be the result of experience, education, and acquired knowledge, according to SIIM.

It will cross the spectrum of imaging informatics knowledge as described in the IIP exam Test Content Outline. No educational course can guarantee that its content will represent the questions on the ABII IIP certification examination, Wilson says.

Himel recommends reading extensively about PACS to prepare for the exam. (See Himel’s reading list in the sidebar at the left.)

How to find an ABII-qualified employee

Today, there are only about 200 qualified CIIP professionals, says Socia, so they may be difficult to find. But the numbers will continue to grow.

If you are looking for a PACS professional in your department or practice, you can simply insert language in your classified advertisement stating that you expect the employee to be IIP certified within a set period of time, such as one year, says Himel.

Insider sources

Bobby Himel, BS, RT(R)(CT)(MR), CIIP, PACS administrator at Baylor Regional Medical Center at Plano, TX, 4700 Alliance Boulevard, Plano, TX 75093, 469/814-2000.

Chuck Socia R.T.(R)(CT)(QM)/CIIP, director of hospital systems at Empiric Systems, LLC, 3800 Paramount Parkway, Suite 130, Morrisville, NC 27560, 866/367-4742; www.Empiricsystems.com.

Caroline Wilson, public relations director at The Society for Imaging Informatics in Medicine, 19440 Golf Vista Plaza, Suite 330 Leesburg, VA 20176-8264, 703/723-0432, Ext. 315; cwilson@siimweb.org.

Exam covers 10 competencies

The following is the basic test content outline (TCO), released by The Society for Imaging Informatics in Medicine (SIIM). SIIM has announced the completion of the overall educational learning objectives or each of the 10 domains of the American Board of Imaging Informatics TCO.

Learning objectives

1. Procurement

Determine organization readiness for the electronic environment

Establish and implement a process for vendor selection

Negotiate contracts with vendors

2. Project management

Identify the goals, scope, risks, and key members of the project team

Evaluate the feasibility of a project

Utilize the common project management tools

3. Operations

Design and implement quality improvement procedures

Develop and implement policies and procedures

Ensure compliance with federal regulations

4. Communications

Recognize roles and relationships in healthcare settings

Communicate with healthcare professionals using appropriate medical terminology

Alert clinical staff members about issues regarding system availability or changes

Provide decision-makers with information about system changes

Develop user feedback mechanisms

5. Training and education

Perform a needs assessment to determine training needs

Evaluate and select training programs according to user needs

Implement training or educational programs

Evaluate effectiveness of training

6. Image management

Manage the design of the environment for viewing and interpreting images

Evaluate the human-computer interface

Determine optimal image flow and implement processes that ensure data integrity

Import and export outside studies into a PACS

7. Information technology

Assess storage and archive needs and determine the appropriate architecture

Design and specify network architecture

Implement and maintain appropriate server hardware and software

Retrieve information from databases for operations, quality assurance, and planning purposes

Identify and implement IT standards

Develop appropriate replacement schedules

Identify key components of PACS architecture and explain connections

8. Systems management

Determine the requirements for optimal, cost-effective system capacity and throughput

Plan disaster recovery and business continuity strategies

Use problem management and system availability tools and strategies

Plan and evaluate data migration procedures

Maintain data security and individual privacy

9. Clinical engineering

Assess imaging modality capabilities

Supervise modality integration

Establish a program for image display quality control (such as explaining what is meant by compliance with the Grayscale Standard Display Function)

Recognize hazards specific to the healthcare environment

10. Medical informatics

Identify and implement medical imaging standards

Apply appropriate Integrated Healthcare Enterprise guidelines

Integrate image architecture into the organization’s long-range plan

How to prepare for the SIIM exam

The Society for Imaging Informatics in Medicine (SIIM) Education Advisory Network is currently developing a core curriculum to further define the Imaging Informatics Professional (IIP) profession and devise a model curriculum and guide for education in the field. (See www.siimweb.org/index.cfm?id=4058.)

To help you prepare, Bobby Himel, BS, RT(R)(CT)
(MR), CIIP, PACS administrator at Baylor Regional Medical Center at Plano, TX, who recently passed the exam, offers the following SIIM resources:

SIIM IIP Symposium (www.siim2008.org/2008IIP.html)

Syllabus that accompanies the symposium (www.siimweb.org/index.cfm?id=231)

SIIM primer series (www.siimweb.org/index.cfm?id=267)

PACS: A Guide to the Digital Revolution

PACS and Imaging Informatics: Basic Principles and Applications

Digital Imaging: A Primer for Radiographers, Radiologists and Health Care Professionals

Handbook of Medical Imaging, Volume 3: Display and PACS

OTech trilogy (three books include subject matter about DICOM, PACS administration, and HL-7)

Check out www.otechimg.com for more options

Know the risks before meeting with compliance vendors

Vendors who want to sell you equipment or drugs that will allow your radiologists to perform a new procedure, or perform an old procedure differently or more accurately, often come armed with coding and reimbursement advice.

As part of their pitch, these vendors will often claim that the new procedures their product will allow you to perform will help your practice quickly recoup the cost of the product—and they’ll even give you the CPT codes to use to maximize your reimbursement.

The problem is that this coding and reimbursement advice could be incorrect. And if your practice relies on incorrect information when making purchasing decisions, the consequences could be dire, both on the business front and the compliance front.

Vendors of drugs, devices, and equipment have one purpose, and that is to sell your practice their product. So anything the vendor says about the product should be considered in a critical light. Objective information is crucial to making a good decision.

Physicians intuitively know to ask for any relevant studies or articles in the medical literature describing the product and its usefulness. And often, physicians will poll colleagues about their experience with the product and do their own research about the product’s clinical value before making a purchasing decision.

Yet these same physicians will often rely on the vendor’s assertions about reimbursement and eventual cost-effectiveness and never think to check the accuracy of the information.

Two main problems can arise if you don’t independently verify information regarding the reimbursement available for using a product and the proper way to code for its use:

➤ The product won’t be cost-effective. Sometimes, a product is medically useful, but it costs the practice money to use it. For example, a vacuum-assisted percutaneous breast biopsy system can make breast biopsies quicker, increase the chances of getting a good -sample, and therefore make life easier for the radiologist and the patient. Vendors tout this aspect, but they often fail to mention—or they misstate—the high cost of supplies. And they don’t say that Medicare reimbursement for the supplies used with every biopsy is so low that most practices lose substantial money—$50–$100—with every biopsy they do on a Medicare patient. Also, the vendor probably won’t mention that the practice can’t bill a Medicare patient for the shortfall. So a practice that sees a lot of Medicare patients should consider these factors when it considers buying this biopsy system.

The practice may still decide that the benefits to its radiologists and patients outweigh the financial loss, or it may decide to wait until reimbursement improves or supply costs decrease before buying the system. Regardless of its decision, a practice that doesn’t consider these factors before buying the equipment is in for a shock.

➤ Bad information creates compliance issues. Vendors will often advise using certain CPT codes for the procedures you can perform using their product. But what if this coding advice is incorrect? You could end up being audited or asked to return large sums to a payer—you might even get into trouble with the Medicare program. Asserting that you relied on the vendor’s advice won’t cut you any slack from the authorities. Yet physicians especially are often insistent that coders use the codes the vendor suggested.

As a result, some practices have been forced to repay large sums because they relied on improper coding advice from vendors. For example, in 2003, Medicare received so many incorrect codes for placement of a vascular closure device, including codes for surgical repair of blood vessels, that CMS issued its own code to try to clear up the confusion.

Setting a policy

Practices that want to stay competitive are constantly on the lookout for new procedures to add to their offerings. And that means they’ll always be in the market for products that will help them do this.

To avoid situations like the ones described above, you should adopt a policy regarding the purchase of new products. The key to making an appropriate decision is to get full information. In delegating those information-gathering tasks, you, as administrator, should establish a policy that plays to everyone’s strengths.

The following steps should be taken:

1. Assign a radiologist to investigate the clinical efficacy of any product that your practice is considering using to perform a new procedure or do a procedure differently.

2. Determine whether any special supplies, drugs, or storage procedures will be necessary if you buy the product and, if so, get an idea of the costs involved.

3. Research the appropriate coding and expected reimbursement for the procedure. Two valuable resources are the AMA and specialty societies such as the American College of Radiology and the Society of Nuclear Medicine. AMA members (or others who pay a fee) can submit coding questions to the organization, and many specialty societies have a coding resource person or committee to assist members. Monitoring online discussion groups will often provide advance warning about reimbursement issues related to new technology.

4. Contact your major payers, as well as Medicare, to determine how they expect you to code the new procedure—and to get a sense of the reimbursement amounts these payers offer.

Your practice should not make any purchasing decisions until all this information has been gathered.

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