Clarity on the New Diagnostic Imaging Ordering Mandate in the “Doc Fix”/ICD-10 Law

Sept. 22, 2014
When President Obama signed into law on April 2 legislation to provide a 12-month “patch” to avert physician pay cuts under Medicare’s SGR law, he also approved new requirements regarding clinical decision support in the ordering of diagnostic imaging tests

When President Barack Obama signed into law on Wednesday, April 2 legislation intended to provide a 12-month “patch” to avert  physician payment cuts under Medicare’s sustainable growth formula (SGR) law, he signed a bill that not only gave doctors participating in the Medicare program a pay-cut reprieve. It is also a piece of legislation that contains several other provisions, including not only a one-year delay of the transition to the new ICD-10 coding system, but also, important new requirements for the implementation of systems to ensure that all ordering physicians making choices about ordering diagnostic imaging tests use federally approved clinical decision support (CDR) tools.

That provision, which went largely unnoticed on Monday, March 31, when the bill was passed by the U.S. Senate (after being passed on March 27 by the House of Representatives), has very important implications for healthcare IT leaders.

On Apr. 2, just hours after President Obama signed the “doc fix” bill into law, Cindy Moran, executive vice president of government relations at the Reston, Va.-based American College of Radiology (ACR), spoke with HCI Editor-in-Chief Mark Hagland, to sort out and clarify exactly what is involved, what will be required of patient care organizations and clinicians, and the timelines around all this. Below are her comments.

Can you walk our readers through the elements involved in the new law around the ordering of diagnostic imaging tests?

There will be two elements to this that the Secretary {Kathleen Sebelius, Secretary of Health and Human Services] has to approve. One is the clinical decision support tools. You’ll have to make these services available at no cost to the ordering physician—at least one clinical decision support opportunity must be made available at no cost to every physician who is in a position to order diagnostic imaging tests.

Number two, embedded in these mechanisms will be appropriateness criteria approved by the Secretary, and they have to be useful, depending on the diagnosis. So if there are specific areas not covered by the appropriateness criteria, then there would be some exemptions [to the requirement to use CDS in test ordering]. If there were gaps, let’s say, in the development of appropriateness criteria, you couldn’t penalize the physician—but since there are no gaps, we don’t envision that to be a concern. The secretary will determine, though, which criteria pass muster, and will deem those. And we expect she’ll deem the ACR criteria, possibly along with others.

How many criteria do you have at the ACR?

We have a comprehensive set of criteria, with the criteria covering something like 190 diagnostic areas. It is an extremely comprehensive set of guidelines. And the American College of Cardiology has developed guidelines for cardio procedures, and we collaborate on a good number of those. So we expect the ACR product to be at least one of the sets of criteria included, as well as others.

What is the timeframe for this to happen?

It goes into effect January 1, 2017. And then there will be benchmarks before that; before that, the Secretary will have to approve what the clinical decision support mechanism is that meets her requirements, and what set of rules of appropriateness criteria will be used. She will deem those appropriate for this program. And we expect the ACR appropriateness criteria to meet those qualifications, but we expect that other sets developed by medical specialty societies might be included as well.

So the bottom line is that this law mandates the use of clinical decision support at the point of the ordering of diagnostic imaging tests on the part of ordering physicians, correct?

Yes, as of Jan. 1, 2017. And in terms of interactions with EMRs, we would expect that these criteria would then be qualified and embedded in those EMRs, depending on which one you’re talking about.

So even though the language of the law does not itself require the use of electronic medical records per se, there is an implied interoperability requirement between any CDR tool and the EMR in which it is embedded, if a doctor is using an EMR, correct?

Yes. And again, for those physicians who don’t have EMRs, then this would be made available at no cost to them. For those practices that don’t order a lot of diagnostic imaging services or who may be in rural areas, one of the requirements is that every physician be given access to these criteria, once they have been approved by the Secretary.

Given that there is a broadly general mandate within the federal government to harmonize actions between any branch or unit of the federal government and others, could you foresee how clinical decision support for diagnostic imaging exam ordering might end up being in the Stage 3 MU requirements?

I’m not an expert on meaningful use, but I would assume that that would be of interest to the meaningful use process.

Are you happy that this is in the law?

We are delighted. This was a very high legislative priority for the College, and we’ve worked on this for the last couple of years. We think this is good policy, and is going in the direction that medicine is going to. This policy was one of several that were embedded din the permanent SGR fix, and we were especially delighted that, even though those negotiations failed and everybody was disappointed by that, the good news is that this policy on appropriateness criteria could be viewed as a microcosm of how Congress wants medical care to move forward in the future. And the supporters of this concept felt that even if we were just going to do a 12-month patch [to physician payment under Medicare], this was a good way to jumpstart physicians and the payer community in order to improve the utilization and ordering of diagnostic imaging services. And this is now permanent law.  So the Social Security Act and Medicare law will be amended so that this will be a part of the law.

You’re standing for responsibility in utilization, then, at ACR, correct? Because this is very different from standing for pure freedom in ordering of diagnostic services.

Exactly. The College supports the appropriate utilization of these services, period. And in every policy we’re trying to push, we’re trying to ensure that the correct study is ordered for the right patients, for the right reasons. If we did anything other than that, in this day and time, it would be irresponsible. And I think because this was infinitely reasonable, that it got such broad, bipartisan support in Congress. So my colleagues and I are happy about this on many levels.

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