Download Hospital Outpatient Prospective Payment System and CY 2009

September 2, 2008
Kerry Weems
Acting Administrator
Centers for Medicare and Medicaid Services
Department of Health and Human Services
Attention: CMS-1404-P
Mail Stop C4-26-05
7500 Security Boulevard
Baltimore, MD 21244-1850
Re:
Medicare Program; Hospital Outpatient Prospective Payment System and CY 2009 Payment Rates;
Proposed Rule
Dear Mr. Weems:
The American College of Radiology (ACR), representing over 32,000 diagnostic radiologists, radiation
oncologists, interventional radiologists, nuclear medicine physicians, and medical physicists, appreciates
this opportunity to comment on the proposed notice “Hospital Outpatient Prospective Payment System
(HOPPS)” published in the Federal Register on July 18, 2008. The ACR would like to present positions on
the following issues: the composite ambulatory payment classification (APCs), packaging issues, contrast
studies, pricing of therapeutic radiopharmaceuticals, transitional pass-through payments and new
technologies, Research Triangle Institute and cost compression, quality measures and hospital quality data
reporting.
Imaging Composite Ambulatory Payment Classifications (APCs)
The Centers for Medicare and Medicaid Services (CMS) is proposing to establish five imaging composite
APCs based on the families of codes used for the multiple imaging procedure payment reduction policy
under the Medicare Physician Fee Schedule (MFS). The proposed new imaging composite APCs include:
•
•
•
•
•
Ultrasound
Computed tomography (CT) and computed tomographic angiography (CTA) without contrast
CT and CTA with contrast
Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) without contrast;
and
MRI and MRA with contrast
The ACR understands that Medicare Payment Advisory Commission (MedPAC) has been urging CMS to
address how they can ensure that economies can be captured when two CT, MR or US studies that are done
on the same patient and in the same session. The ACR believes that composites may be a good way to
ensure that CMS is capturing this data and thus, any savings. As the ACR has commented previously, the
level of savings vary between CT, MR, and US with respect to time and resources used when two studies
are done on a patient in the same session. The use of composite APCs is preferable to the arbitrary
reduction for multiple imaging services previously proposed by CMS. Hospitals are supposed to report
their actual costs and thus, these differences could be better reflected in actual reporting rather than with
specified percentages.
1
The ACR believes important issues need to be addressed before implementing the five composites for CT,
MR, and US. However, if CMS chooses to move forward there are a few changes that ACR believes must
take place in order for hospitals to avoid creating incentives for hospitals to provide these services on
different days and thus, inconveniencing patients. We performed a detailed analysis of CMS claims to
assess the impact of the CMS proposal. CMS’ proposed methodology appears to be reasonable when two
studies are done in the same session. However, when three or more studies are performed in the same
session the extra margin in the payment reduces significantly. The CMS data shows that three or more CT
and MR studies are billed in the same session at least 25 percent of the time multiple examinations are
billed. The ACR requests that CMS review at these cases and consider the development of a separate
composite methodology for those instances where more than two CT, MR, or US exams are performed in
the same session. If the payment for three or more studies is not increased, the ACR is concerned that
hospitals will break out the studies into separate imaging sessions and inconvenience the patient by
scheduling them for more than one visit to provide all the necessary imaging needed to diagnose their
condition. Our findings are summarized in the table below.
APC
8004
8005
8006
8007
8008
Number of Procedures on Same Date of Service within the Composite APC
2 Procedures
3 Procedures
4 Procedures
5 Procedures
>5 Procedures
96.40%
2.57%
0.27%
0.17%
0.04%
81.83%
15.88%
1.65%
0.32%
0.15%
71.39%
25.06%
2.94%
0.42%
0.16%
84.92%
11.82%
2.15%
0.78%
0.30%
73.50%
20.67%
3.92%
1.25%
0.66
The ACR also requests that if CMS moves forward with the proposed composite methodology that the CT
and MR studies that are done with and without contrast (and described by a single CPT code) be broken out
into separate APCs. These studies grouped in with other “with contrast” studies causes their median
payment level to drop significantly. The payment rates to CT and MR with and without contrast studies
would be more stable in their separately assigned APCs. The ACR is concerned that hospitals will not be
able to adjust to these issues in time before the outpatient prospective payment system (HOPPS) Final Rule.
Below is an example of three CT procedures with contrast with CMS’ proposed payment and composite
single session payment.
Example: Three CT Procedures with Contrast
Codes on Same Date of Service
72193
71260
74160
Q9965
Total
CMS Proposed 2009 Payment
Rate per Separately Paid
Procedure
$ 310.46
$ 310.46
$ 310.46
$0
$931.38
Composite Single Session APC
Rate
$ 639.09
In addition to our concerns about the potential re-scheduling of patients for a separate session when the
imaging services are performed in a non-emergency situation, we also are concerned that the drop in
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payment when three or more imaging studies are done in the same session will have a significant and
immediate negative impact on hospital trauma centers.
Packaging Issues
Technical Comments on Increasing the Number of Single Claims for Codes with Q1 or Q2 Status
Indicator
The ACR commented extensively on the packaging of imaging into other procedures under CMS’ new
methodology in 2007. As a result, CMS created the distinction between “STVX-packaged” and “Tpackaged” which significantly increased the number of single claims for these codes. In this proposed rule,
the ACR appreciates the fact that the methodology is much more transparent, but we are concerned that the
programming logic for capturing the costs of codes with Q1 and Q2 status indicators on single claims is not
selecting sufficient number of data to be used in rate setting for the imaging codes that could otherwise be
promoted to “majors”.
“Q1 and Q2 packaged” are procedures that can be packaged (status indicator of N) based on the presence of
other codes on the claim on the same day, otherwise they become procedures in their own right. A
procedure with status indicator Q1 is packaged if there are any procedures on the same day with status
indicators: S, T, U, or X. A procedure with a status indicator Q2 is packaged if there are any other
procedures on the same day with status indicator T. Otherwise, the procedures are “promoted” and become
majors. Note that there are special sets of rules if there are multiple procedures with status indicator Q1 or
Q2 on the same day.
Currently, the determination of whether or not the line is to be packaged is made at the very start of the ratesetting process. The result appears to be that more lines are packaged than are necessary or appropriate.
For example, take the case of a claim that on a single day has two bypass codes and a procedure with a Q1
status indicator. The current logic would change the Q1 status indicator to an N, and then apply the ratesetting methodology. The methodology would then extract the two bypass codes creating pseudo-singles
from them, leaving a single code with a status indicator N, which would not be used.
If instead, the conditional status indicator (Q1) was assessed at each stage of the process, this Q1 status
indicator line could be “promoted” to a single major after removal of the bypass codes, allowing this line to
be used in the rate setting.
In the example just presented, this alternative approach is consistent with current CMS policy to not include
packaging with bypass codes, but then also to attempt to use as much of the HOPPS data as possible.
Technical Comments on Packaging Imaging “Dependent” Codes into Independent Codes
CMS packaged image guidance and supervision and interpretation (S&I) codes into their corresponding
“independent” procedural codes last year under the assumption that the S&I codes are always incident to
another paid procedure. Under this assumption, a significant proportion of the costs associated with the
packaged codes that are included on single claims should be captured through the “independent” paid
procedures. However, CMS’ recently released 2007 data show that a number of guidance or S&I
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“dependent” codes are not on claims with paid procedures as often as 75% or more of the time. In some
cases, when bypass codes are removed the packaged procedures are left on a claim with no other paid
procedure and are dropped from rate-setting. In the situation where a packaged procedure is only included
in rate setting 5 percent or 10 percent or 25 percent of the time, the hospitals using those technologies will,
in fact, not be reimbursed for most of the costs associated with those procedures.
The ACR urges CMS to carefully check to make sure that packaging and composite APC methodologies
are working correctly before expanding their use into more comprehensive groupings. The ACR would like
to explore developing composite APCs with CMS in order to be able to capture more multiple claims data
to be used in the rate-setting methodology in the future. The ACR requests that CMS make the preliminary
packaging and composite data available to the public for review as soon as possible. This would allow
for stakeholders to determine if the packaging and composite methodologies are meeting the goals of
capturing accurate multiple claims data. It also would allow stakeholders to be able to make more accurate
suggestions of future changes within their specialty areas of interest.
Packaging of Image Guided Radiation Therapy
Our analysis of the packaging of image guided radiation therapy (IGRT) indicates that the CMS
methodology includes only a small percentage of the costs of the packaged services in the calculation of the
payment rates for the APCS into which they are packaged. We are concerned that inappropriately low
payment rates will slow the adoption and continued use of this valuable technology.
The ACR recommends that the packaging of IGRT be eliminated in CY 2009. The ACR supports the
APC Advisory Panel’s most recent recommendation to unpackage Image Guided Radiation Therapy
(IGRT) from treatment delivery and pay separately for two years. The ACR believes CMS must address
the underlying problems in the methodology that eliminates a significant percentage of the costs of IGRT
from the calculation of the costs of the independent APCs.
Packaging of CT Guidance in Placement of Radiation Therapy Fields
If CMS is going to continue to package, then CT guidance for the placement of radiation therapy fields
should have a Q status indicator for those instances where it is the only service provided at the hospital.
Patients are often sent to the hospital for a CT for which the purpose is to send these images over to a
separate cancer treatment center or facility to be used to set up the cancer patient’s simulation and treatment
plan for radiation therapy. The ACR has been receiving phone calls already asking how to handle this
situation.
The ACR recommends placing a Q status indicator on the code for CT guidance for the placement of
radiation therapy fields to eliminate confusion and allow for this standard of patient care to continue.
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Contrast Studies
The ACR has conducted an analysis to determine if the multiple claims data used to determine the median
APC weight for contrast-enhanced studies would improve if CMS required a contrast code to always be
present on a claim with a contrast-enhanced study. The findings below indicate that the number of claims
used in rate setting would be less but the quality of the data with respect to more accurate payment rates for
contrast procedures would be improved if an edit policy were implemented similar to that of
radiopharmaceuticals and nuclear medicine studies.
Effect of Potential Edit Requiring Presence of Contrast Code with Imaging Procedure Codes
for HOPPS Ratesetting
Source: 2007 Claims Released with 2009 Proposed HOPPS Rule
APC
Procedure
0274
0337
Myelography
CT with
Contrast
Ct w/o
followed by w/
MRI/MRA w/o
followed by w/
0662
CTA
0283
0333
Single
Frequency
Under
Current
Policy
Single
Frequency
With Edit
Median
Cost
Under
Current
Policy
1,051
203
$384.43
$625.08
43,528
$10,475,050.53
510,345
369,329
$309.92
$315.19
3,061,256
$16,127,785.24
219,658
159,159
$345.02
$346.75
846,682
$1,462,209.17
524,712
375,434
$545.35
$558.02
805,225
$10,201,523.97
125,021
93,198
$357.01
$369.02
389,298
$4,673,904.56
Median
Cost
With
Edit
Total
Frequency
in 2007
Impact
The ACR requests that CMS require that at least one contrast code be on a claim for an imaging service
that requires contrast in order for it to be used in rate-setting. The ACR believes that this will ensure
that the packaged costs of contrast are being captured in the contrast-enhanced APCs for which contrast
is packaged. Attachment 1 is a list of CPT codes that ACR has identified as procedures that use contrast.
Pricing of Therapeutic Radiopharmaceuticals
For CY 2009, CMS proposes to pay for therapeutic radiopharmaceuticals under the standard drug payment
method, based on average sales price (ASP) + 4 percent , when reported by the manufacturer through the
standard CMS ASP reporting mechanisms. If ASP is not available, CMS would determine payment based
on the mean costs of the therapeutic radiopharmaceutical, derived from hospital claims data. Pricing of
radiopharmaceuticals has continued to be a challenge and the ACR is concerned that because of the low
volume, certain high priced radiopharmaceuticals’ full costs are not being captured in the HOPPS under the
conventional hospital charge data.
Shortly after publication of the proposed rule, the Medicare Improvements for Patients and Providers Act of
2008 (MIPPA) continued the mandate that hospital outpatient payments for therapeutic
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radiopharmaceuticals will be based on the individual hospital’s charges reduced to costs until December 21,
2009.
The ACR supports this legislative change and recommends that it be made permanent by CMS in CY
2010 and beyond through regulation.
Pricing of Diagnostic Radiopharmaceuticals
The ACR believes that CMS should provide preliminary and ongoing data that shows the outcome of CMS’
packaging of diagnostic radiopharmaceuticals into nuclear medicine APCs in order to determine exactly
how hospitals are reporting their costs on these very important studies and drugs. The ACR also requests
that CMS ensure that nuclear medicine APCs that have packaged diagnostic radiopharmaceuticals do not
violate the two-times rule. Correct pricing of radiopharmaceuticals is particularly important as we head into
the era of molecular imaging. If the cost of these new radiopharmaceuticals cannot be captured by the
hospitals, there will be disincentive to provide these new and potentially life saving treatment options to
Medicare beneficiaries.
Transitional Pass-through Payments and New Technologies
The ACR supports CMS’ acknowledgement that new diagnostic and therapeutic radiopharmaceuticals qualify
for transitional pass through payment for up to three years. The ACR urges CMS to keep these new drugs in
the transitional pass through status for the full three year time frame in order to ensure that costs are
calculated on an adequate amount of data, especially for low volume high cost radiopharmaceuticals,
before they are incorporated into regular APCs. The ACR understands that CMS should not double pay for
the use of a radiopharmaceutical with a nuclear medicine procedure and supports taking the offset off of the
procedure in order to preserve the data for the new drug and its correct establishment into the APC system.
The ACR requests that CMS be careful to assure that accurate data are used when calculating the offset
and that those data be made available stakeholders to ensure stability and accurate payment for the entire
study through the transitional period.
The ACR continues to be concerned with how new technologies are being handled under HOPPS. There has
not been consistency of: 1) When they are assigned to new technology APCs; 2) How long they remain in
new technology APCs; and 3) When they are assigned to regular APCs.
The ACR requests that CMS consider consistently placing new technologies in new technology APCs
similar to how CMS is suggesting it will handle pass-through payments for radiopharmaceuticals. This
would allow for new technologies to be in a neutral category, where cost data can be collected and then the
appropriate placement can be made, hopefully with stable cost data, in a regular APC. The ACR requests
improvement and consistency in the placement of new technologies and how they are handled under
HOPPS. These services are the cutting edge advances in medicine that need to be available for future
patient care.
6
Research Triangle Institute (RTI)/Cost Compression
The ACR appreciates that CMS is not proposing to adopt any short-term adjustments to the HOPPS
payment rate calculations for 2009 and agrees that the changes RTI suggests are complex and that CMS
should proceed with caution. The ACR supports CMS’ efforts to work on educational activities for
hospitals to improve their cost reporting. We believe that educational efforts to help hospitals to more
accurately report their costs for high cost services like CT and MRIs is especially important.
The ACR remains very concerned about the effects of charge compression on the pricing of new and highcost technologies in hospital charge masters and how this affects the payment of these technologies under
the HOPPS. The recent RTI reports on charge compression (January 2007 and April 2008) show low costto-charge ratios (CCRs) for advanced imaging services such as MR and CT scans. One set of RTI estimates
suggests that hospitals on average mark up CT services by more than 1800 percent over cost (CCR of
0.054), compared to an average markup of just over 300 percent for routine radiology costs (CCR of 0.308).
This roughly five-fold differential in markup of these high cost imaging studies seems too large to be an
accurate reflection of typical hospital charging behavior. Accordingly, we believe the RTI CCRs are
implausibly low and would result in substantial distortion of payments if used for calibrating Medicare
rates.
The use of these CCRs for setting Medicare payment rates would significantly reduce payment for imagingintensive Diagnosis Related Groups (DRGs) such as those for trauma services. But the impact on the
HOPPS and technical payments under the physician fee schedule would be more dramatic. Currently, CMS
uses a CT- or MR-specific CCR for about a third of hospitals in the HOPPS rate calculation. Expanding
that, by using the RTI CCRs through out or by following RTI’s lead in re-assigning cost report line
designations, would cause an inappropriate reduction in the HOPPS rates. Furthermore, due to the Deficit
Reduction Act (DRA) caps on payments in the MFS, these HOPPS reductions would spill over onto
services performed in non-hospital outpatient settings.
The ACR hired Christopher Hogan, Ph.D. to examine this issue for us. Dr. Hogan concluded that the
measured CCRs for advanced imaging may reflect a mis-allocation of capital costs on the cost report. That
is, a significant number of hospitals report little or no capital costs for MR and CT. Therefore, these
hospitals may be treating CT and MR machines as hospital fixtures (allocated to hospital overhead) instead
of equipment (allocated to radiology cost). If this is so, RTI’s estimate of the costs and CCRs for CT and
MR are substantially too low.
Regardless of the actual reason for the low CCRs, the use of the RTI CCRs could result in some highly
anomalous payments. For example, as shown below, they could result in higher payment for x-ray than for
a similar CT scan. They could also result in physician fee schedule rates for technical component costs of
CT scans to be less than CMS’ own estimate of cost of the CT scanner alone (let alone all other costs
associated with the service), even under the assumption of full-time use of the scanner. This would
effectively prohibit physicians from providing these services. This also strongly suggests that hospitals
would find it highly unprofitable to provide these services at those rates.
To illustrate this we performed a payment rate and cost calculation for x-ray versus CT scan of the head.
These services image the same part of the body and take roughly the same amount of time (24 and 26
minutes respectively, based on the 2008 physician practice expense data). Because the treatment of capital
cost may be the key issue, we compare projected HOPPS payments using the RTI CCRs to the estimated
7
direct (no overhead) equipment cost per procedure from the physician fee schedule practice expense
calculation.
Table 1 shows what the use of these CCRs would imply for the Medicare HOPPS. To calculate the
projected HOPPS rates, we started from the current OPPS rate. We adjusted that using the ratio of the RTI
CCRs to the actual HOPPS CCRs used to create those rates (the average CCR on single-procedure claims
using calendar year 2006 HOPPS claims).
Table 1 shows that the use of the RTI CCRs would create several anomalies in the rates. First, the RTI
regression-based CCRs would result in paying more for x-ray ($99) than for the corresponding CT service
($65). In effect, that set of CCRs says that x-ray is more costly than CT. Second, while the RTI rates always
exceed the equipment cost of the x-ray service, they are often substantially below the equipment cost of the
CT service. Using CMS’ current assumption of an average 50 percent use rate, neither of the HOPPS rates
based on the RTI CCRs would be enough to pay for the cost of the equipment. We emphasize that this is
just the cost of amortizing and maintaining the equipment, and does not include the additional personnel,
supplies, and overhead costs actually involved in providing that service. Even at an assumed full-time (100
percent) use rate, the RTI-based HOPPS rates would barely cover the CT equipment cost or fall just below
the CT equipment cost. The clear implication here is that using the RTI CCRs to calculate the HOPPS rates
(and hence the DRA physician fee caps) would make it impossible to offer CT services in stand-alone
outpatient settings such as physician offices, and would make those services substantially unprofitable in
hospital outpatient settings.
Table 1: Projected HOPPS Rates Versus Estimated Equipment Cost per Procedure, Using RTI Costto-Charge Ratios
Payment Rate, Actual 2008
Payment Rate Using 2008
RTI CCR, cost report
Payment Rate Using 2008
RTI CCR, regression
70450 Ct head/brain w/o dye (26 minutes)
Cost-to-Charge Ratio
0.160
0.066
0.054
Actual or Projected
HOPPS Rate
Phy. Equipment Cost,
50% Use Rate
$192
$79
$65
$144
$144
$144
Difference, Payment less
Eq. Cost
$48
-$65
-$79
Phy. Equipment Cost,
100% Use Rate
$72
$72
$72
$120
$7
-$7
0.230
0.191
0.308
$74
$61
$99
Difference, Payment less
Eq. Cost
70260 X-ray exam of skull (24 minutes)
Cost-to-Charge Ratio
Actual or Projected
HOPPS Rate
8
Phy. Equipment Cost,
50% Use Rate
$14
$14
$14
Difference, Payment less
Eq. Cost
$60
$47
$85
$7
$7
$7
Difference, Payment less
Eq. Cost
$67
$54
$92
Memo: Ratio of CT to
Xray rate
2.59
1.30
0.66
Phy. Equipment Cost,
100% Use Rate
Sources: Physician cost calculated from 2008 physician final rule practice expense data, using CMS
methodology, at 50 percent and 100 percent use rate. Current HOPPS CCRs calculated from single
procedure claims extracted from the Propose Rule 2008 HOPPS file. RTI CCRs taken from the April
2008 RTI report to CMS on charge compression. Projected rates calculated as current rate time ratio of
RTI to current CCR.
The ACR requests that CMS not implement the adjustments recommended in the RTI reports and
continue to study this further. Implementation of these methodological changes without further review
and analysis of the hospital claims data could have severe negative impacts on both the hospital
outpatient and non-hospital settings for those sites that offer CT and MR services.
Proposed Quality Measures for CY 2010 Hospital Outpatient Payment Determination
As required by law, CMS is proposing to reduce the annual HOPPS payment inflation update by 2 percent
for hospitals that do not meet quality reporting requirements beginning in CY 2009. The ACR is concerned
that hospitals may be inappropriately penalized for not being able to comply with reporting quality
measures due to lack of funding and time. New hospital claims systems can cost as much as $50 million.
Hospitals will need to upgrade their hospital electronic medical record systems in order to have the data
fields available to report the quality measures. Rural hospitals may need to install new electronic medical
record systems if they do not have an electronic medical record system. This new requirement also
increases the need for staff to collect the measures and report accurately.
The ACR requests that CMS not penalize hospitals by cutting their payments by 2 percent if they can
demonstrate that they currently are working to comply with the reporting requirements but do not yet
have the infrastructure to fully comply.
For a hospital to receive the full outpatient update payment factor in 2010, CMS proposes reporting on four
new imaging efficiency measures, along with continued reporting on the seven quality measures in place
during the initial measurement reporting period of the HOP QRDP in 2008. The ACR commented on these
measures in December 2007. Since that time, any revision to measure specifications has not been made
publicly available. Included in Attachment 2 are our previous comments.
9
The ACR is concerned that the four new imaging measures proposed for reporting in 2009 are not
appropriate to be included in the 2010 payment year because they are still in the developmental phase.
These measures have not yet received National Quality Forum (NQF) endorsement nor have they been
considered for adoption by the AQA-HQA Collaboration – Quality Alliance Steering Committee (QASC).
Adoption of appropriate performance measures and continued progress in constructively improving quality
of care requires meaningful public comment on quality measures that have been broadly vetted at the
stakeholder level and needs to occur through adoption of measures by the QASC and endorsement by the
NQF.
In the proposed rule, CMS did not provide critical information about the proposed measures, such as
measure specifications, an appropriate rationale for each measure, discussion of the evidence underlying the
measures, an explanation of the expected value of putting the measure into place, nor any indication of
previous measure testing or results of testing. Rulemaking is intended to provide the opportunity for public
comment, but this cannot be achieved when a proposal is so vague and incomplete that it prevents
meaningful comment.
Accordingly, we urge CMS to not adopt the four imaging measures at this time and to re-evaluate the
measures at such time as essential measure specification, NQF endorsement, and QASC consideration
can be accomplished.
CMS’ current proposal with regard to these imaging measures is unclear both in the detail of the measures
and the method of implementation. CMS is proposing to “adopt” the four imaging measures beginning with
the CY 2010 payment determination and states that CMS will calculate the measures using CY 2008
Medicare Part B claims data. This is elusive and vague as to how compliance with reporting the measures is
determined – since, unlike the existing seven HOP QDRP measures, measure data is not reported but
derived from claims. It is unclear whether compliance is based on “reporting” through claims submission,
or whether compliance is based on an unknown performance rate. CMS also did not provide hospitals fair
notice or due process that 2008 claims would potentially be used for the purpose of measure analysis, for
payment update determination or for publicly available comparative data. Services billed on CY 2008
claims are being provided now. Hospitals did not have the opportunity to review and understand the
implications of the measures or make changes in their processes or care prior to use of claims for measure
analysis. It is also unclear as to how CMS will attribute measure performance or reporting compliance,
because imaging measures may require analysis of Medicare beneficiary claims from multiple facilities, as
in the case of the MRI Lumbar Spine measure.
The ACR requests clarification on the form and manner of reporting the imaging measures and urges
CMS to not adopt these measures in any manner until specific information as to implementation is
provided through due process.
CMS states that it intends to harmonize measures to be used in the HOP QDRP with measures that can be
or are already adopted in comparable inpatient and ambulatory care and across settings and providers and to
use the same measure specifications. When harmonizing measures across settings, CMS should be specific
as to what the particular entity is accountable or responsible. Moreover, measures that relate to physician
performance in the hospital outpatient setting should be aligned with physician measures utilized in other
CMS quality programs, such as the Physician Quality Reporting Initiative (PQRI).
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The newly enacted MIPPA calls for the Secretary to contract with a consensus-based organization like the
NQF, to develop and report annually, to the Secretary and Congress on goals and priorities and specific
measures to help health care providers meet those goals and procedures, and for the Secretary to then set
national goals. It seems that the outcome of such a priority setting process could greatly inform and focus
future measures to be considered in the outpatient setting.
The ACR urges CMS to work with stakeholders, especially the AMA PCPI, NQF, and the QASC, to
prioritize any new measures and to work to ensure that newly selected measures align with overall
national goals for quality improvement.
Conclusion
Thank you for the opportunity to comment on this proposed rule. The ACR looks forward to continued
dialogues with CMS officials. Should you have any questions on the items addressed in this comment
letter, please contact Sneha Soni at (800) 227-5463, ext. 4576 or via email at [email protected].
Respectfully Submitted,
Harvey L. Neiman, MD, FACR
Executive Director
Cc:
Carol Bazell, MD, MPH, CMS
Edith Hambrick, MD, CMS
Tamar Spolter, MHS, CMS
Bibb Allen, MD, FACR, Chair, ACR Commission on Economics
Richard R. Duszak, Jr., MD, FACR, Vice-Chair, ACR Commission on Economics
James V. Rawson, MD, Chair, ACR Economics Committee on HOPPS/APC
Pamela J. Kassing, ACR
Maurine Spillman-Dennis, ACR
Angela J. Kim, ACR
Sneha J. Soni, ACR
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Attachment 1
Procedures that Use Contrast
0145T
0150T
0151T
70460
70470
70481
70482
70487
70488
70491
70492
70496
70498
71260
Computed tomography, heart, without contrast material
followed by contrast material(s) and further sections,
including cardiac gating and 3D image postprocessing;
cardiac structure and morphology
Computed tomography, heart, without contrast material
followed by contrast material(s) and further sections,
including cardiac gating and 3D image postprocessing;
cardiac structure and morphology in congenital heart
disease
Computed tomography, heart, without contrast material
followed by contrast material(s) and further sections,
including cardiac gating and 3D image postprocessing,
function evaluation (left and right ventricular function,
ejection-fraction and segmental wall motion) (List
separately in addition to code for primary procedure)
Computed tomography, head or brain; with contrast
material(s)
Computed tomography, head or brain; without contrast
material, followed by contrast material(s) and further
sections
Computed tomography, orbit, sella, or posterior fossa or
outer, middle, or inner ear; with contrast material(s)
Computed tomography, orbit, sella, or posterior fossa or
outer, middle, or inner ear; without contrast material,
followed by contrast material(s) and further sections
Computed tomography, maxillofacial area; with contrast
material(s)
Computed tomography, maxillofacial area; without
contrast material, followed by contrast material(s) and
further sections
Computed tomography, soft tissue neck; with contrast
material(s)
Computed tomography, soft tissue neck; without contrast
material followed by contrast material(s) and further
sections
Computed tomographic angiography, head, with contrast
material(s), including noncontrast images, if performed,
and image postprocessing
Computed tomographic angiography, neck, with contrast
material(s), including noncontrast images, if performed,
and image postprocessing
Computed tomography, thorax; with contrast material(s)
cardiovascular
system
cardiovascular
system
cardiovascular
system
Neuro
Neuro
Head and Neck
Head and Neck
Head and Neck
Head and Neck
Head and Neck
Head and Neck
Head and Neck
Head and Neck
Chest
12
71270
71275
72126
72127
72129
72130
72132
72133
72191
72193
72194
73201
73202
73206
73701
73702
73706
74160
Computed tomography, thorax; without contrast material,
followed by contrast material(s) and further sections
Computed tomographic angiography, chest
(noncoronary), with contrast material(s), including
noncontrast images, if performed, and image
postprocessing
Computed tomography, cervical spine; with contrast
material
Computed tomography, cervical spine; without contrast
material, followed by contrast material(s) and further
sections
Computed tomography, thoracic spine; with contrast
material
Computed tomography, thoracic spine; without contrast
material, followed by contrast material(s) and further
sections
Computed tomography, lumbar spine; with contrast
material
Computed tomography, lumbar spine; without contrast
material, followed by contrast material(s) and further
sections
Computed tomographic angiography, pelvis, with contrast
material(s), including noncontrast images, if performed,
and image postprocessing
Computed tomography, pelvis; with contrast material(s)
Computed tomography, pelvis; without contrast material,
followed by contrast material(s) and further sections
Computed tomography, upper extremity; with contrast
material(s)
Computed tomography, upper extremity; without contrast
material, followed by contrast material(s) and further
sections
Computed tomographic angiography, upper extremity,
with contrast material(s), including noncontrast images, if
performed, and image postprocessing
Computed tomography, lower extremity; with contrast
material(s)
Computed tomography, lower extremity; without contrast
material, followed by contrast material(s) and further
sections
Computed tomographic angiography, lower extremity,
with contrast material(s), including noncontrast images, if
performed, and image postprocessing
Computed tomography, abdomen; with contrast
material(s)
Chest
Chest
Neuro - Spine and
Pelvis
Neuro - Spine and
Pelvis
Neuro - Spine and
Pelvis
Neuro - Spine and
Pelvis
Neuro - Spine and
Pelvis
Neuro - Spine and
Pelvis
Spine and Pelvis
Pelvis
Spine and Pelvis
Upper Extremities
Upper Extremities
Upper Extremities
Lower Extremities
Lower Extremities
Lower Extremities
Abdomen
13
74170
Computed tomography, abdomen; without contrast
material, followed by contrast material(s) and further
sections
Computed tomographic angiography, abdomen, with
contrast material(s), including noncontrast images, if
performed, and image postprocessing
Computed tomographic angiography, abdominal aorta
and bilateral iliofemoral lower extremity runoff, with
contrast material(s), including noncontrast images, if
performed, and image postprocessing
Computed tomography, heart, without contrast material
followed by contrast material(s) and further sections,
including cardiac gating and 3D image postprocessing;
computed tomographic angiography of coronary arteries
(including native and anomalous coronary arteries,
coronary bypass grafts), without quantitative evaluation
of coronary calcium
Computed tomography, heart, without contrast material
followed by contrast material(s) and further sections,
including cardiac gating and 3D image postprocessing;
computed tomographic angiography of coronary arteries
(including native and anomalous coronary arteries,
coronary bypass grafts), with quantitative evaluation of
coronary calcium
Computed tomography, heart, without contrast material
followed by contrast material(s) and further sections,
including cardiac gating and 3D image postprocessing;
cardiac structure and morphology and computed
tomographic angiography of coronary arteries (including
native and anomalous coronary arteries, coronary bypass
grafts), with quantitative evaluation of coronary calcium
Abdomen
0149T
Computed tomography, heart, without contrast material
followed by contrast material(s) and further sections,
including cardiac gating and 3D image postprocessing;
cardiac structure and morphology and computed
tomographic angiography of coronary arteries (including
native and anomalous coronary arteries, coronary bypass
grafts), with quantitative evaluation of coronary calcium
cardiovascular
system
70542
Magnetic resonance (eg, proton) imaging, orbit, face,
and/or neck; with contrast material(s)
Magnetic resonance (eg, proton) imaging, orbit, face,
and/or neck; without contrast material(s), followed by
contrast material(s) and further sequences
Magnetic resonance angiography, head; with contrast
material(s)
Neuro - Head and
Neck
Neuro - Head and
Neck
74175
75635
0146T
0147T
0148T
70543
70545
Abdomen
Aorta and Arteries
cardiovascular
system
cardiovascular
system
cardiovascular
system
Neuro - Head and
Neck
14
70546
70548
70549
70552
70553
70554
70555
70558
70559
71551
71552
71555
72142
72147
72149
72156
Magnetic resonance angiography, head; without contrast
material(s), followed by contrast material(s) and further
sequences
Magnetic resonance angiography, neck; with contrast
material(s)
Magnetic resonance angiography, neck; without contrast
material(s), followed by contrast material(s) and further
sequences
Magnetic resonance (eg, proton) imaging, brain
(including brain stem); with contrast material(s)
Magnetic resonance (eg, proton) imaging, brain
(including brain stem); without contrast material,
followed by contrast material(s) and further sequences
Magnetic resonance imaging, brain, functional MRI;
including test selection and administration of repetitive
body part movement and/or visual stimulation, not
requiring physician or psychologist administration
Magnetic resonance imaging, brain, functional MRI;
requiring physician or psychologist administration of
entire neurofunctional testing
Magnetic resonance (eg, proton) imaging, brain
(including brain stem and skull base), during open
intracranial procedure (eg, to assess for residual tumor or
residual vascular malformation); with contrast material(s)
Magnetic resonance (eg, proton) imaging, brain
(including brain stem and skull base), during open
intracranial procedure (eg, to assess for residual tumor or
residual vascular malformation); without contrast
material(s), followed by contrast material(s) a
Magnetic resonance (eg, proton) imaging, chest (eg, for
evaluation of hilar and mediastinal lymphadenopathy);
with contrast material(s)
Magnetic resonance (eg, proton) imaging, chest (eg, for
evaluation of hilar and mediastinal lymphadenopathy);
without contrast material(s), followed by contrast
material(s) and further sequences
Magnetic resonance angiography, chest (excluding
myocardium), with or without contrast material(s)
Magnetic resonance (eg, proton) imaging, spinal canal
and contents, cervical; with contrast material(s)
Magnetic resonance (eg, proton) imaging, spinal canal
and contents, thoracic; with contrast material(s)
Magnetic resonance (eg, proton) imaging, spinal canal
and contents, lumbar; with contrast material(s)
Magnetic resonance (eg, proton) imaging, spinal canal
and contents, without contrast material, followed by
contrast material(s) and further sequences; cervical
Neuro - Head and
Neck
Neuro - Head and
Neck
Neuro - Head and
Neck
Neuro - Head and
Neck
Neuro - Head and
Neck
Neuro - Head and
Neck
Neuro - Head and
Neck
Neuro - Head and
Neck
Neuro - Head and
Neck
Chest
Chest
Chest
Neuro - Spine and
Pelvis
Neuro - Spine and
Pelvis
Neuro - Spine and
Pelvis
Neuro - Spine and
Pelvis
15
72157
72158
72159
72196
72197
72198
73219
73220
73222
73223
73225
73719
73720
73722
73723
73725
74182
74183
74185
Magnetic resonance (eg, proton) imaging, spinal canal
and contents, without contrast material, followed by
contrast material(s) and further sequences; thoracic
Magnetic resonance (eg, proton) imaging, spinal canal
and contents, without contrast material, followed by
contrast material(s) and further sequences; lumbar
Magnetic resonance angiography, spinal canal and
contents, with or without contrast material(s)
Magnetic resonance (eg, proton) imaging, pelvis; with
contrast material(s)
Magnetic resonance (eg, proton) imaging, pelvis; without
contrast material(s), followed by contrast material(s) and
further sequences
Magnetic resonance angiography, pelvis, with or without
contrast material(s)
Magnetic resonance (eg, proton) imaging, upper
extremity, other than joint; with contrast material(s)
Magnetic resonance (eg, proton) imaging, upper
extremity, other than joint; without contrast material(s),
followed by contrast material(s) and further sequences
Magnetic resonance (eg, proton) imaging, any joint of
upper extremity; with contrast material(s)
Magnetic resonance (eg, proton) imaging, any joint of
upper extremity; without contrast material(s), followed by
contrast material(s) and further sequences
Magnetic resonance angiography, upper extremity, with
or without contrast material(s)
Magnetic resonance (eg, proton) imaging, lower extremity
other than joint; with contrast material(s)
Magnetic resonance (eg, proton) imaging, lower extremity
other than joint; without contrast material(s), followed by
contrast material(s) and further sequences
Magnetic resonance (eg, proton) imaging, any joint of
lower extremity; with contrast material(s)
Magnetic resonance (eg, proton) imaging, any joint of
lower extremity; without contrast material(s), followed by
contrast material(s) and further sequences
Magnetic resonance angiography, lower extremity, with
or without contrast material(s)
Magnetic resonance (eg, proton) imaging, abdomen; with
contrast material(s)
Magnetic resonance (eg, proton) imaging, abdomen;
without contrast material(s), followed by with contrast
material(s) and further sequences
Magnetic resonance angiography, abdomen, with or
without contrast material(s)
Neuro - Spine and
Pelvis
Neuro - Spine and
Pelvis
Neuro - Spine and
Pelvis
Spine and Pelvis
Spine and Pelvis
Spine and Pelvis
Upper Extremities
Upper Extremities
Upper Extremities
Upper Extremities
Upper Extremities
Lower Extremities
Lower Extremities
Lower Extremities
Lower Extremities
Lower Extremities
Abdomen
Abdomen
Abdomen
16
75561
75562
75563
75564
77058
77059
Cardiac magnetic resonance imaging for morphology and
function without contrast material(s), followed by contrast
material(s) and further sequences;
Cardiac magnetic resonance imaging for morphology and
function without contrast material(s), followed by contrast
material(s) and further sequences; with flow/velocity
quantification
Cardiac magnetic resonance imaging for morphology and
function without contrast material(s), followed by contrast
material(s) and further sequences; with stress imaging
Cardiovascular
System
Cardiac magnetic resonance imaging for morphology and
function without contrast material(s), followed by contrast
material(s) and further sequences; with flow/velocity
quantification and stress
Magnetic resonance imaging, breast, without and/or with
contrast material(s); unilateral
Magnetic resonance imaging, breast, without and/or with
contrast material(s); bilateral
Cardiovascular
System
Cardiovascular
System
Cardiovascular
System
Breast
Breast
17
Attachment 2
Measure #1: MRI Lumbar Spine for Low Back Pain
There is general support for this measure as the exam is one of the most over utilized imaging exams.
However, there are several substantial issues with the measure as currently constructed.
1. Attributability/determination of previous conservative therapy
It is suggested that the measure results be segmented and reported by rendering provider. If CMS
retrospectively analyzes claims data to search and correlate imaging and conservative therapy, is the
measure then attributable to the imaging or rendering provider rather than the referring provider?
a. Complete details of a patient treatment plan and history are often unavailable to imaging provider,
particularly for patients originating from outside of the health system doing imaging.
b. Conservative therapy is often supervised by generalists who refer patients who do not respond to
conservative treatment to specialists. Specialists often order MRI immediately without more
conservative therapy. The MRI referring physician may not appear in administrative data, though
the patient may have had extensive exercise, over the counter medications during the period of the
acute episode.
c. It will be difficult to measure conservative therapy such as bed rest or over the counter pain
medications utilized. This is especially important, because the use of self care techniques is
advised in order to avoid “over medicalization” of episodic lumbar pain and radiculopathy.
2. Relevance
As stated above, the rationale for the intent of the measure is recognized and supported, but in the
manner constructed it may not provide the most useful data. The following is offered for consideration:
a. Rate when the ordering and interpreting physician are one and same would be of interest.
b. A large percentage of cases are referred by orthopedic or neuro surgeons, in which case most
patients would have undergone conservative therapy. Those without conservative therapy often
come from the emergency room.
c. More and more frequently insurers deny claims on patients without conservative therapy.
3. Diagnoses codes used for inclusion in measure inaccurate or incomplete
a. Using ICD9 codes specific to lumbar conditions from imaging procedure claims may not gather
patients into the denominator that would be expected since studies without definitive diagnosis for
lumbar disease will be coded with specific findings. This is problematic because a high proportion
of lumbar spine imaging reveals findings not distinguishing normal from abnormal subjects in the
Gaussian sense. Therefore, “normal” results may indicate a high quality of radiological
performance – that certain degenerative findings are often seen in normal subjects, such as disk
protrusions (722.2). Consider a patient with disk protrusion on right side but pain on left side.
Also, there are other indications for a lumbar MRI other than for suspected neurological deficit
such as for spinal therapeutic injections. The MRI determines the level for the injection and which
levels have adequate epidural fat to inject.
b. The measure needs to take into account “red flag” indications for the lumbar MRI. Clinical
indications of a more complicated low back pain condition include:
18
1) Recent significant trauma, or milder trauma, age >50
2) Unexplained weight loss (783.2)
3) Unexplained fever (780.6)
4) Immunosuppression (279.3)
5) History of cancer
6) IV drug use
7) Prolonged use of corticosteroids, osteoporosis
8) Age>70
9) Focal neurologic deficit, progressive or disabling symptoms
c. Important clinical indications for MRI not addressed
For patients with acute significant motor or sensory loss or those with a known malignancy and
sudden back pain with normal radiographs, an urgent MRI would be standard of care.
4. Other concerns
a. A more specific definition of “false positive misinterpretation” referred to in Section I of the
measure is needed. Does this allude to incorrect identification of a finding or a problem of
correlating the imaging finding with the clinical complaint?
b. Malpractice issues – in an environment of capricious malpractice courts, especially in cases
alleging a “failure to diagnose” or a “delay in treatment” where is protection for a physician who
conscientiously attempts to follow prescribed policies? It must be noted that cauda equina
syndrome is among the more frequent causes of litigation.
Measure #2: Mammography Follow-Up Rates
1. Lack of understanding of mammography practice operations
The discussion states that high recall rates are an indication of absence of real-time review of screening
exams, and that the most efficient delivery of diagnostic mammography services is that which is
contemporaneous with the initial screening. This seems to indicate a lack of understanding of the
operational processes and efficiencies, and conditions required for optimal image interpretation for most
sites performing and interpreting screening mammograms. In order to best utilize resources and services
of radiologists interpreting mammograms, it is most efficient to conduct “batch reading” of images. In
this way the radiologist is not rushed in the interpretation, images are more easily organized and patients
are not “collecting” in the waiting area stressing the system.
As the number of radiologists willing to review mammograms is declining, in many locales there are few
who are immediately available to do real time reading. Real time reading, or on the fly interpretation
would require a major change in logistics, radiologist and technologist staffing and likely lead to lower
productivity. This in turn could result in longer wait times for patients before their screening
mammograms can be scheduled. Additionally, since ultrasound is frequently used for additional imaging
after a screening mammogram, ultrasound would also be necessary at a screening mammography site.
Because qualified ultrasound technologists are in short supply, it would be counterproductive to
encourage a practice style that would result in waste of this scarce resource.
19
It must be noted that any gains in patient convenience that might be derived from avoiding a return visit
by 10 percent of women who are recalled for additional study will almost certainly be more than fully
offset by the additional time that the 90 percent who require no additional imaging will be detained at the
mammography center awaiting preliminary interpretation of the screening mammogram. Some of these
patients will require recall in any event if the preliminary impression is revised upon reflection, or
ultrasound, for example, is not available at the moment. In addition, this style of practice is not feasible
for extended hours, mobile mammography outreach, rural or inner city satellite clinics and other
methods to increase screening prevalence.
Additional concerns with real-time reading will be discussed below.
2. Unintended consequences
Same day diagnostic mammography
The measure is seriously flawed in setting “on the fly” interpretation as the ideal method for
mammography. This is an inefficient way to perform screening mammography (which normally would
increase the cost in most other economic situations), but also is the most distracting way, which does not
allow the mammographer to concentrate on screening. Error rate in interpretation may increase in real
time reading. There is literature that suggests the superiority of batch film reading where conditions are
controlled and decisions are made in an orderly fashion (ES Burnside, et al AJR: 185, September 2005).
This study showed that batch reading can significantly reduce screening mammography recall rates
without affecting the cancer detection rate or the proportion of cancers diagnosed with favorable
prognostic indicators. Also, prior mammograms are typically reviewed prior to assigning a final
assessment code or a decision for further work up. Reviewing prior films (which frequently come from
outside facilities and can take weeks to arrive) will impact the decision for more imaging or a BIRADS
category 1 or 2 assessment.
The same day approach may lead to more overall diagnostic studies way above 10 percent recalled
(patient already there, not inconvenienced to get additional view). Real-time interpretation of screening
mammograms has been shown to be associated with a statistically significant higher recall rate than
batch reading (Ghate et al. Radiology 2005;235:31-35). A same day diagnostic will still cause separate
charges, additional radiation, and patient anxiety (although less so than a request to return). This seems
contrary to the goal of the measure.
The costs of imposition of same day diagnostic services on screening programs would negatively impact
access and population screening rates, particularly for under- and uninsured populations as well as
underserved rural and urban populations.
Population based screening attempts to increase access through efficiency and economy. If the
radiologist looks at every screening exam before the patient leaves the efficiency of high volume is lost.
Furthermore, scarce physician resources would be consumed in this inefficient screening approach that
could be better utilized in diagnostic mammography, breast ultrasound, and biopsy.
Recall Rate
Administrative data sets such as that available to CMS are easily used to calculate surrogate recall
(abnormal interpretation) rates, but that rate must be defined properly and use a valid conceptual
construct. The measure appears not to take into account the following:
20
•
Stating that a recall rate greater than 10 percent is “unusually high” means that 50 percent of the
radiologists in the cited study (Rosenberg et al. Radiology 2006; 241:55) have a recall rate that is
unusually high.
• Emphasizing recall rates could very well be detrimental to patient care. Too low a call back rate is
problematic in terms of good care if efforts to lower recall result in decreased early detection of
cancer. The Technical Panel (TEP) of imaging experts that was convened to advise L&M, The
Lewin Group and the National Imaging Associates (NIA) voiced this very concern. There are no
established, proven methods for lowering recall rates without potentially sacrificing cancer
detection rates. For this reason the mammography measures developed in the AMA Consortium
Workgroup focused on ensuring individual sites/radiologists developed a system for calculating and
reviewing their own recall rates.
• The statement in the proposed metric that “unusually high” recall rates are due to “the inability of
the reader to adequately determine when additional imaging is necessary (high false positive rate)”
is not necessarily true. Actually, the inability of a reader to determine when additional imaging is
necessary may lead to lower recalls. A high false negative rate has more serious implications for
patients than a high false positive rate.
• Studies have shown that American women prefer and are willing to tolerate a high false positive
rate in order to detect more cancers.
• Same day diagnostic services must not be excluded from abnormal interpretation rate. Additional
views beyond the normal screening must be included in the abnormal interpretation (recall) rate.
After all, additional radiation dose, anxiety, etc. result from the additional views.
3. Relevance
While shorter time to call back completion seems obviously better, the total time from initiation of
contact to completion is important. You are farther ahead if you get the initial mammogram completed in
40 days and call back 14 days later than wait 100 days for a screening and get called back in three.
Most radiologists in the United States interpret a relatively small volume of screening mammograms per
year. 54 percent of radiologists in the US do fewer than 2000 mammograms per year (screening and
diagnostic), (Institute Of Medicine (IOM) 2005). As a result, recall rates often will show statistical
variation from one year to the next, even in the face of consistent performance by the radiologists,
strictly on the basis of random chance. This is, particularly true for those radiologists who interpret the
minimum number of mammograms required under Mammography Quality Standards Act (MQSA).
It is strongly recommended that if the data collection specified in this measure is done, a desired “follow
up” level should not be mandated. Doing so would likely result in decreased numbers of qualified breast
imagers with a resultant decrease in patient access to mammography.
4. Measure construction, incomplete codes
a. The measure should include CPT codes for all procedures that would capture true abnormal
interpretation rate within a period of time that is reasonable to allow a patient to return for a
21
diagnostic exam or other downstream service.
• Extend the 45 day period following a screening mammography to 7 months to capture those
given an (inappropriate) initial screening assessment category of “probably benign” (BIRADS
3) to capture the six month follow up screening exam
• Include same day diagnostic exam in recall rate
b. No reference or guideline was given for the 5 day recall timeframe. Literature suggests at least 14
days as a median (RYabroff, et al AJR 2007; 188:242-245). Delay also must consider patient
availability.
Measure #3: Abdomen CT – Use of Contrast Material
Overall, both measures focusing on use of contrast material were felt to be reasonable and an area where
evaluation is warranted. Measuring referring physician performance may be much more relevant than
radiology performance to the frequency of acute imaging. Several recommendations are provided below.
1. Relevance
As constructed, the measure may could catch potential outliers in terms of underutilization (for example
for sites that do not have anyone to start IVs), but given the high rate of use of contrast material, it would
be difficult to confirm over-utilization just from the perspective of the percentage of use of contrast
material per patient. Performance of combined with and without contrast studies as a percentage of total
abdominal CT scans should be the main area of evaluation rather than “questionable utilization of
contrast agents”. Insurance data has shown 15 to 54 percent variation in use of combined exams, even
after some level of intervention. The ACR analysis on the variability of CT abdomen procedures across
states based on 2006 Medicare shows a national average of twice (.50) as many with contrast only
procedures as without and with contrast combined, but a range at state level from .13 to 1.28
(combined/with contrast only).
2. Measure construction, incomplete codes
Looking at ratios of contrast, no contrast, with and without is relatively easy from administrative data
(e.g., CPT) codes. However the differences between practices may by due to differences in patient mix.
The relative frequency of renal, pancreatic or adrenal mass in the practice as compared with other
indications such as flank pain or abdominal pain will affect the relative frequency with which contrast,
non contrast and with and without contrast examinations are performed. Contrast use is a function of the
population of patients with renal dysfunction, which can vary strongly by institution. Another variable is
the lack of use of contrast on follow-up in some categories of patients. Also a factor is a high frequency
“rule-out stone” requests typically coming from the Emergency Department. Risk adjustment or
stratification on the basis of ICD9 codes for relevant clinical syndromes or pathological conditions ought
to be performed.
Red flag indications for combined studies:
Unspecified disorder of kidney and ureter
Hematuria
Benign, essential, idiopathic
593.9
599.7
22
Schistosoma haematobium
Pancreatic
Hypoglycemia, unspecified
Hypoglycemia with coma
In diabetes mellitus
Leucine-induced
Adrenal mass
Unspecified disorder of adrenal glands
120.0
251.2
251.0
250.8
270.3
255.9
Measure #4: Thorax CT – Use of Contrast Material
1. Relevance
There is concern that the measure is evaluating performance of studies with contrast. The focus should
be on routine use of combined, not studies with contrast only. During a recent review of the ACR
Thoracic CT guideline, thoracic experts debated largely whether the basic exam should be with contrast
or without. There was no argument for routine use of combined studies. There are clear indications to
use without contrast for parenchyma and calcification, with contrast for adenopathy or practice expense.
23