Otolaryngologists who provide computed tomography (CT) imaging are being urged to apply before summer to ensure their compliance with the 2008 Medicare Improvements for Patients and Providers Act (MIPPA) accreditation requirement.
“The time is now, and it gets shorter by the second,” said Pamela A. Wilcox, RN, MBA, assistant executive director for quality and safety with the American College of Radiology (ACR).
Section 135(a) of MIPPA stipulates that as of Jan. 1, 2012, all suppliers who furnish the technical component of advanced diagnostic imaging (ADI) and bill under the physician fee schedule must be accredited in order to receive payment from CMS/Medicare (Federal Register, Nov. 25, 2009; Vol. 74, No. 226, p. 61865).
Otolaryngologists who have installed limited use (cone beam or volume) computed CT scanners fall under this rule, as do those who offer conventional CT. Other ADI modalities, such as MRI and PET scans, are also included in the rule, but the focus is primarily on cone beam CT scans, which have recently increased in ENT practices. Accreditation can take three to four months (longer if initial accreditation is delayed due to deficiencies), but initiating the application process early can help avoid a logjam at the end of the year.
It is not known how many currently unaccredited otolaryngologists use the cone beam scanners. General Manager Steven Meier of Xoran Technologies (Ann Arbor, Mich.), the major supplier of cone beam CT scanners to ENT practices, said the company has installed “hundreds” of its miniCATs in ENT practices. Their installations have not been correlated with accreditation applications, however.
“There is no magic list as to who the impacted providers are. That’s why we’re taking steps to reach out to otolaryngologists and their administrators to make sure they’re aware of this effective date,” said Tamara A. Sloper, director of marketing for the Intersocietal Accreditation Commission (IAC).
Writing on the Wall
The CMS/MIPPA accreditation rule was triggered by concerns about cost and utilization. A Congressional-commissioned report, MedPac Report to the Congres in June, 2005, noted a 22 percent spending increase for imaging services under the physician fee schedule in 2004 alone. The report also questioned whether all the increases represented services that beneficiaries needed.
Concerns about radiation dosage and safety have also played a role, according to Gavin Setzen, MD, FACS, FAAOA, president-elect of the Intersocietal Commission for the Accreditation of Computed Tomography Laboratories (ICACTL) and principal of Albany ENT & Allergy Services, PC in Albany, N.Y. The National Institutes of Health, for example, held a Feb. 24-25 summit focusing on management of radiation dose in CT in Bethesda, citing a three-fold increase in CT scans from 1999 to 2009.
“Imaging is at an interesting crossroads,” Dr. Setzen said. “As more physicians perform advanced imaging services as part of their office practices, there are concerns about radiation dose exposure and safety, cost and utilization. Accreditation is the route to address these concerns. It takes unqualified personnel and poor quality out of the picture, and provides a more standardized mechanism for performance and interpretation, for reimbursement and, most importantly, for safety of the patient.”
Michael Sillers, MD, past president of the American Rhinologic Society and owner-operator of Alabama Nasal and Sinus Center in Birmingham, Ala., didn’t wait for Medicare’s deadline. As a solo practitioner who uses a limited cone beam CT scanner for diagnosis and treatment planning, he started his accreditation process in 2009. “You could see the writing on the wall,” he said. “We knew [accreditation] was coming.” In fact, United Healthcare (UHC) was the first payer in Alabama to announce accreditation as a requirement for reimbursement. (UHC later suspended its 2008 deadline in deference to the impending CMS/MIPPA rule.)
“As more physicians perform advanced imaging services as part of their office practices, there are concerns about radiation dose exposure and safety, cost and utilization.”
—Gavin Setzen, MD, FACS, FAAOA
Which Accrediting Organization?
In January 2010, CMS/Medicare, as mandated by Congress, designated the ACR, The Joint Commission and the IAC as the three accrediting organizations (AOs). Each has developed and maintains its own program standards and protocols, and although Medicare does not dictate those programs, the agency did outline parameters that any standards used should address, such as:
- qualifications for personnel who furnish the technical component of imaging services;
- qualifications of facilities’ medical directors and supervising physicians, which can be the same person, depending on the AO;
- equipment specifications and procedures; the assurance of operator and patient safety; and
- ongoing quality assurance programs.
Although each AO has a three-year accreditation cycle, there are program differences that will determine which organization providers choose.
Since 1963, the ACR has provided accreditation for diagnostic imaging and radiation oncology. The supervising physician for the ACR accreditation program can be a board-certified radiologist or diagnostic radiologist, or another physician who has completed continuing medical education units and has interpreted and reported on 500 cases within the last 36 months. A distinctive feature of the ACR process is the requirement to submit phantom images. The ACR does not accredit the cone beam scanners. If a practice uses a full-body scanner, physicians “can visit the ACR website to see whether their images will meet our requirements,” Wilcox said. For a summary of the ACR’s CT Accreditation Program Requirements, go to acr.org/accreditation/computed/ct_reqs.aspx.
The IAC, established in 1989, uses an intersocietal approach, drawing from a range of medical specialties—in addition to radiology—to develop its program standards for a variety of testing modalities.These include CT, echocardiography, magnetic resonance imaging and others. The board of directors responsible for generating the CT standards included AAO-HNS members Dr. Setzen and Arnold Noyek, MD, professor of otolaryngology-head and neck surgery at the University of Toronto. The ICACTL accreditation program offers a pathway for otolaryngologists who both perform and interpret their scans, providing they meet one of the training and experience pathways as outlined in the standards. For the established practice pathway, for example, the medical director must have a minimum of five years of CT experience, have at least 150 hours of Category 1 CME, have interpreted a minimum of 500 CT examinations, and have radiation safety training. To view other training and experience pathways and additional requirements, download the ICACTL Standards at icactl.org/icactl/main/icactl_standards.htm.
The Joint Commission’s approach, according to Michael Kulczycki, executive director of the Ambulatory Care Accreditation Program, is to accredit the practice instead of simply the imaging technology, with attention to both patient and staff safety. To meet the CMS mandate for ADI accreditation, The Joint Commission has an add-on option to its accreditation process that includes assessment of the equipment and operating personnel.
“We do an on-site survey for every applicant and a re-survey every three years,” Kulczycki said. “Our on-site process is a major part of our accreditation process.” The Joint Commission has been receiving applications from oral and maxillofacial surgeons who use the cone beam technology. For more information, go to jointcommission.org/Imaging or surveymonkey.com/s/DGNFF7M
Unless otolaryngologists are using conventional CT technology, the ICACTL “makes the most sense for the average ENT practitioner,” Dr. Sillers said. “The lion’s share of the CTs otolaryngologists perform are paranasal sinus and temporal bone,” he pointed out.
Gather Your Resources
According to Dr. Setzen, the accreditation process is a fairly rigorous one. “But,” he added, “It is easily accomplished if done properly and with the help of others, including the practice administrator, the imaging manufacturer and the accrediting organization. The CT technologist and medical physicist will be important to the process if the practice is using conventional CT.”
Jolene Eicher, executive advocate of the Association of Otolaryngology Administrators, said talking to other practice managers who have been through the process is helpful. Advanced ENT and Allergy in Louisville, Ky., where Eicher is the COO, is currently awaiting the results of its re-accreditation. She recalls receiving many phone calls from other practice managers three years ago, when the first wave of accreditation requirements hit due to UHC’s initial deadline. Xoran offers accreditation assistance to its customers, which can be accessed at xorantech.com/accreditation.php.
Representatives from the AOs recommend visiting their organizations’ websites to peruse standards and protocols before applying. In addition, said Mary Lally, the IAC Technical Director, ICACTL has a web page summarizing common deficiencies that lead to accreditation delays. Go to intersocietal.org/iac/news/2010/autumn/div_icactl/CT_delay_issues.htm.
More information on maintaining compliance is also available at intersocietal.org/icactl/accredits/maintaining_compliance.htm.
Other Benefits
In Alabama, the major payer is Blue Cross/Blue Shield, which has added Dr. Sillers to its list of preferred radiology providers (PRPs) now that he has been granted accreditation. As a PRP, his online pre-certification process for performing a CT scan is shorter.
“The payer has looked at the foundation of accreditation [with its medical necessity standards and safety protocols] and assumes that you are ordering and interpreting scans appropriately,” Dr. Sillers explained. “That makes the pre-certification process a little less cumbersome.”
Another benefit can accrue to the practice through the accreditation process. “This isn’t a process where you submit your material, pay your fee, obtain accreditation and are finished for three years,” Lally said. “Accreditation is a continuous quality assurance and quality improvement process.”
Eicher said Advanced ENT and Allergy’s quality assurance committee meets quarterly to review indications for CT scans as well as the quality of the films. The entire accreditation process, she said, “takes the private practice into an area where health care is headed with the new Recovery Act. Eventually, physicians will be asked to do quality measurements, so putting a quality assurance committee in place puts you a little ahead of that curve.”