Radiology Administrator's Compliance & Reimbursement Insider, June 2007

“Diagnostic imaging, when performed in high-quality and safe centers, is critical to optimal medical care outcomes,” said Reed V. Tuckson, MD, UHc’s executive vice president and chief of medical affairs, in the January UHc release.

Baby-steps help accreditation process begin

Accreditation shouldn’t seem too difficult, says Katanick. In fact, most facilities should find their current processes already in alignment with association accreditation standards, she suggests.

“The more organized an imaging site is, the easier it will be to complete the accreditation application,” says Paidosh.

Use the following tips to get started:

Meet the application deadline. Order materials and start the process ahead of any accreditation deadlines, regardless of whether they are insurer-imposed. Paidosh encourages centers to submit their applications now to avoid any compliance concerns come March 1, 2008. Once you have your materials from either the IAC or the ACR, follow submission instructions carefully. Both groups maintain time-limits and strict deadlines.

Know your quality control standards. ACR committees developed quality assurance standards for nearly every modality of radiology to help facilities establish and maintain their own quality programs. IAC also looks for documentation of quality assurance programs, so it makes good sense to review these policies with your staff.

Perform every image as if your accreditation depended on it. Too often, jobs become routine and those performing them don’t realize the importance of their behaviors. It isn’t just a facility’s accreditation on the line when it doesn’t perform an imaging procedure appropriately or calibrate a scanner correctly—it could be someone’s life.

Make sure that you send only the finest-quality work to the accreditation body. And always have your interpreting physician review the work prior to sending your completed accreditation package.

Use all of the resources available. Read through the ACR manual and explore its Web site (www.acr.org). Examine the various tools available on the IAC Web site (www.intersocietal.org) and talk to other facility managers and administrators. Ask a qualified medical physicist and your facility’s radiologists for assistance. Do not try to do it alone.

Keep accurate records and make duplicates. Your dog didn’t eat it, and it didn’t get lost in the mail, but sometimes people misplace a file. Prevent this common mistake from costing you UHc reimbursement money or stalling accreditation by making a copy of everything you send to the accreditation association.

Keep the paperwork on file at your facility as a back-up. That way, if reviewers ask questions, the paperwork and potential answers remain right at hand.

Early prep-work prevents accreditation ogres

A lot of reimbursement money remains at risk if independent imaging facilities neglect to comply with the new UHc accreditation policy.

But fulfilling the requirements shouldn’t seem like a paperwork nightmare.

“If facilities do nothing more than download and review the standards right away, they’ll be in a better position to take on the accreditation process. It’s not an impossible task. Administrators just need to realize its not an overnight process,” says Tamara A. Sloper, IAC’s marketing director.

“The more organized an imaging site is, the easier it will be to complete the accreditation application,” says Paidosh.n

Insider sources:

Sandra Katanick, CEO, Intersocietal Accreditation Commission, 8830 Stanford Boulevard, Suite 306, Columbia, MD 21045, 410/872-0100; katanick@intersocietal.org.

Laurie Paidosh, director of radiology programs, UnitedHealthcare, 5901 Lincoln Drive, Edina, MN 55436, 952/992-5708; www.unitedhealthcareonline.com.

Tamara A. Sloper, director of marketing, Intersocietal Accreditation Commission, 8830 Stanford Boulevard, Suite 306, Columbia, MD 21045, 410/872-0100; sloper@intersocietal.org.

W. Geoffrey West, M.Eng., DABR, CHP, president, West Physics Consulting, 4339 Oakdale Vinings Circle SE, Smyrna, GA 30080, 770/435-9186; info@westphysics.com.

Accreditation help on the Web

Examining UnitedHealthcare’s accreditation minutiae

Beginning March 1, 2008, UnitedHealthcare (UHc), one of the nation’s largest third-party payers, will reimburse freestanding facilities and physician offices for magnetic resonance (MR), CT, PET, nuclear medicine, and certain other procedures only if those facilities receive accreditation from either the American College of Radiology (ACR) or the Intersocietal Accreditation Commission (IAC).

Many imaging facilities considered accreditation voluntary, though in recent years a smattering of payers started tying accreditation to reimbursement.

The UnitedHealthcare Imaging Accreditation Program includes expertise and accreditation standards developed by both the ACR and the more than 22 sponsoring organizations of the IAC.

In the highly specialized, ever-changing imaging world, “accreditation programs have emerged as key initiatives to advance quality and safety of imaging studies,” says Laurie Paidosh, director of radiology programs at UHc. “It is important that consumers receive services from facilities that are in compliance with established performance standards.”

Meet the associations

ACR is a national professional organization serving more than 32,000 imaging professionals. It boasts more than 16,000 accredited member facilities across the United States. The IAC is a national nonprofit organization, comprised of the following five distinct groups:

Specific medical specialty associations sponsor each of the IAC member groups. For example, the American College of Cardiology, the American Society of Echocardiography, the Society for Vascular Surgery, and other professional groups support ICAVL.

Sandra Katanick, CEO of the IAC, expects imaging centers to choose the accreditation body that best meets their needs. Facilities may choose to obtain accreditation from one organization or both. Both associations maintain a three-year accreditation window.

IAC’s Marketing Director Tamara A. Sloper says each organization maintains a slightly different focus. The IAC review concentrates on clinical case studies and peer review, she says, whereas the ACR requires heavy clinical review and phantom testing. The IAC may receive more requests for cardiac laboratories, whereas the ACR may receive more from radiology facilities, due to each group’s previous experience and expertise, she says.

Both associations’ fees for accreditation vary by modality and number of machines.

The IAC charges $200–$250 to download accreditation standards and supporting materials, and from $1,500 for echocardiography to $3,800 for comprehensive nuclear medicine accreditation. The ACR charges $100– $750 in membership dues (although membership is not required) and $900–$2,100 for accreditation fees, depending on the number of modules and the number of facilities. UHc worked with the ACR and the IAC over the past year to develop the new payer accreditation policy, says Katanick. “So, we’ve both been getting ready for the increase.”

Insider sources:

Sandra Katanick, CEO, Intersocietal Accreditation Commission, 8830 Stanford Boulevard, Suite 306, Columbia, MD 21045, 410/872-0100; katanick@intersocietal.org.

Laurie Paidosh, director of radiology programs, UnitedHealthcare, 5901 Lincoln Drive, Edina, MN 55436, 952/992-5708; www.unitedhealthcareonline. com.

Tamara A. Sloper, director of marketing, Intersocietal Accreditation Commission, 8830 Stanford Boulevard, Suite 306, Columbia, MD 21045, 410/872-0100; sloper@intersocietal.org.

Accreditation requirements spur physicists to action

The phones at West Physics Consulting started ringing off the hook as soon as UnitedHealthcare (UHc) an-nounced its new accreditation requirement.

In order to receive UHc payment after March 1, 2008, affiliated independent diagnostic testing facilities and physician offices operating imaging equipment need either American College of Radiology (ACR) or Inter-societal Accreditation Commission (IAC) accreditation.

With more than 10,000 facilities slated for accreditation, and fewer than 100 physicists in the country able to perform the necessary equipment tests associated with ACR accreditation requirements, W. Geoffrey West, M.Eng., DABR, CHP, president and CEO of West Physics in Atlanta, expects an assessment gridlock.

“You really have to feel for these facilities,” West says. “They’re caught in a difficult situation, and many don’t even know about the new requirements.”

In fact, the IAC expedited its new CT accreditation requirements posting them on its Web site in April.

CT specifics add to accreditation traffic concerns

West estimates that 65% of MRI units in the United States obtained accreditation already.

However, only 15% of CT units have received accreditation for that modality, he estimates. Also, facilities with multiple modalities (e.g., CT and MRI, or CT and PET) need multiple accreditations, which could add to the assessment bottleneck.

CT scans represent the greatest accreditation challenge from the physicist’s perspective, West says. “It’s very meticulous. Regions of interest must be laid out properly. It takes hours and hours of prep work.” Multi-detector CT scanners challenge physicists further, he says. “You have to know how the detector is configured. You can’t just go through a simple procedure to do the accreditation.”

Increased assessment equals increased business

Typically, medical physicists operate on a “mom-and-pop” business model, with two or three physicists working in a given geographic area. Because hospitals often employ their own physicists, those staff members often moonlight their expertise to independent diagnostic imaging facilities and physician offices.

However, with UHc’s new accreditation requirements, there’s an increased demand for specialized physicists’ knowledge. “It’s really grown from a fragmented industry with limited expertise requirements to an extremely complicated analytical field,” says West. “Most physicists are competent in x-ray surveys. That’s what they do every day.”

But fewer physicists can perform the necessary analysis on the newer, more complicated machines.

Finding the right physicist takes time

Freestanding facilities and physician offices with imaging equipment may not have a medical physicist on staff. In fact, says West, although most large hospitals do employ a medical physicist, it’s an anomaly in the freestanding diagnostic imaging world. Unfortunately, consulting medical physicists can be hard to find. Internet searches will locate the more established firms but many firms rely exclusively on word-of-mouth marketing.

The important thing is to assess the physicist’s experience and pass rate with accreditation on each modality and to compare educational credentials and board certifications (such as from the American Board of Radiology).

The practice of medical physics applies the principles and accepted protocols of physics to ensure the correct quality, quantity, and placement of radiation during the radiological procedure, according to the American Association of Physicists in Medicine (www.aapm.org).

Medical physicists take care of equipment testing, device specification, and image quality assessment,as well as ensure that all the science behind imaging mechanics works the way it’s supposed to.

Insider source:

W. Geoffrey West, M.Eng., DABR, CHP, president, West Physics Consulting, 4339 Oakdale Vinings Circle SE, Smyrna, GA 30080, 770/435-9186; info@westphysics.com.

Ask the Insider:

Including additional scans after findings as protocol

Q: Radiologists in our department have proposed to add reporting for incidental findings to our ultrasound protocols. The topic continues to surface in a variety of situations at our facility. We’ve discussed incidental findings in gallstones seen with a renal study, abdominal aortic aneurysms seen in a liver study, and so forth. I was trained to image the incidental finding and make note of my impressions when reporting to the interpreting radiologist. But with so many coding changes in recent years, I am unsure whether this is an appropriate practice anymore. The radiologists have proposed a protocol change to refrain from imaging incidental findings until contacting the ordering physician for an appropriate order to evaluate the finding.

Can you clarify the rules and regulations regarding incidental-finding imaging?

A: No one likes to pay for the same meal twice. It might have tasted really good, but once it’s down the gullet, it’s gone. The same idea applies (in general) to imaging procedures. If you scan once, you code and bill once.

Look to the professional edition of the 2007 CPT requirement to document abnormalities for proof.

Parenthetical notes for abdominal ultrasound exams include the required anatomical organs or regions and end with the words “including any demonstrated abdominal abnormality.”

The extent of the imaging of the abnormality provided does not matter. If you have a single image of an abnormality or create a detailed photo library, the coding remains the same.

It would also be improper to perform what, in essence, would be an additional reportable procedure (e.g., cyst on kidney turns into additional images amounting to a renal ultrasound) because of an incidental finding.

Medicare frowns on charging for additional exams that the referring physician did not order, as well as providing additional services that are not coded and/or billed.

Many physicians expand their routine protocols to include additional views.

However, additional views do not mean additional charges or codes. The number of images or views one obtains does not affect ultrasound coding.

The code selection is based on the anatomical structures visualized.

Insider source:

John Marshall, CRA, RCC, RT®, prospective payment coordinator, Sarasota Memorial Healthcare System, 2433 Huntington Avenue, Sarasota, FL 34232, 941/716-5657;john-marshall@smh.com.

Tip: Audit procedures for anti-kickback and Stark laws

According to the Office of Inspector General’s (OIG) Compliance Program Guidance for Hospitals, hospitals should have policies and procedures in place to address state and federal anti-kickback statutes, as well as the Stark physician self-referral law.

Such policies should provide that the following are true:

Make sure that the policies and procedures address and define the OIG’s safe harbor regulations, which outline payment practices that would be immune from prosecution under the anti-kickback statute.

He said, he said: Physicians discuss imaging ownership

Some say radiologists understand the science and art of body imaging better than anyone. Although cardiologists may agree with that premise, they say that they know the structure and beat of the heart better than the backs of their hands—and certainly better than radiologists do.

So who should perform cutting edge scans of the heart and vasculature—radiologists or cardiologists? Two experts weighed in on the matter during the December 2006, HCPro, Inc., audioconference “The 64-Slice CT Scanner: The latest battleground in specialty turf disputes.”

Radiologists say

The primary reason to maintain cardiac imaging procedures under radiologists’ supervision—if not outright ownership—is because of their expertise with the equipment, argued Michael Nicholas Brant-Zawadzki, MD, FACR, medical director of the radiology department at Hoag Memorial Hospital Presbyterian in Newport Beach, CA.

“Arguing that cardiologists should read a heart scan is to argue that a neurologist should read a brain CT scan or a gastroenterologist should read an abdominal CT scan,” he said.

This concern earned decades-long debate, Brant-Zawadzki said. “The role of the radiologist represents the specialization in imaging technology across the entire body. Part of a radiologist’s core competence is whole-body imaging—understanding the principals with which those images are obtained,” he said.

Radiologists work on a daily basis with a variety of cutting-edge technologies for many studies. Further, Brant-Zawadzki argued, radiologists better understand radiation risks, physics, and the engineering behind equipment selection and scanner operations.

Also, radiologists know how to select the proper radiation settings, assign technologist protocols, establish policies for contrast-agent administration, and understand the myriad details that take place prior to the actual data acquisition and analysis of the image. After obtaining the images, data-processing work for two- and sometimes three-dimensional images still remains. Such scans often require additional time dedication and a separate skill set, he said.

“All of these particulars are second nature to a radiologist,” said Brant-Zawadzki. “Some of our cardiology colleagues simply think it’s a matter of looking at the images. We’re seeing many cardiologists who want to get involved, but who do not understand what comes first.”

Once cardiologists understand the complete nature of new cardiac-imaging technologies—the postprocessing, slicing and dicing of arterial images and the examining of various projections—their interest in performing these complex procedures may become clearer, he said.

“These problems still need to be worked out.” Brant-Zawadzki said.

Cardiologists say

Cardiologists know the heart—that’s their primary argument for including their professional analysis into new cardiac imaging technology procedures.

Heart specialists say their interest in cardiac imaging revolves around whatthey’re imaging, not the technology itself.

With so much information included in a cardiac CT, applying that information to a particular patient for prognosis and treatment often proves onerous. “That’s my bias for cardiologists to understand this [new] technology,” said Timothy Albert, MD, a cardiologist at Central Coast Cardiology, in Salinas, CA.

“When we start seeing all this information, we have to go back and see the patient and ask ‘Does this information apply to him or her?’ ‘Is this a finding which requires physician follow through?’ ” Cardiologists offer the best answers to those questions, he said.

Cardiologists bring a great deal to the table, agreed Brant-Zawadzki. “Their knowledge of coronary artery disease [CAD] is much more in-depth than radiologists’.” But, he argued, many radiology programs cover CAD basics today, and radiologists who chose to specialize in heart imaging take advance training in both technology and anatomy through cardiovascular fellowships.

Patients in need of cardiac imaging require cardiologist’s care, suggested Albert. “These are patients that cardiologists are very comfortable with. It fits our professional experience very well.”

Albert pointed to previous cardiology involvement with ultrasound for the heart. “We all adopted it,” he said, not because it represented new technology or new payment avenues, “but because we saw opportunity for improved care.

That’s why there’s so much excitement” around cardiac imaging even now.

Editor’s note: To purchase a prerecorded copy of the audioconference, visit www.hcmarketplace.com/prod-4874.html.

Insider sources:

Michael Brant-Zawadzki, MD, FACR, radiology department medical director, Hoag Memorial Hospital Presbyterian, One Hoag Drive, P.O. Box 6100, Newport Beach, CA 92658-6100, 949/764-5942; mbrant@hoaghospital.org.

Timothy Albert, MD, cardiolgist, Central Coast Cardiology, 230 San Jose Street, Salinas, CA 93901, 831/758-2100; timothy.albert@gmail.com.

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