Radiology Business Journal June/July 2011

June/July 2011

The Great CT Bundling Heist of 2011 Featured in this issue A Dry Run for Three New Efficiency Measures | page 12 The Top Five Imaging IT Projects of 2010 | page 37 The Lure and the Legend of Clinical IR | page 45

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June/July 2011

The Great CT Bundling Heist of 2011 Featured in this issue A Dry Run for Three New Efficiency Measures | page 12 The Top Five Imaging IT Projects of 2010 | page 37 The Lure and the Legend of Clinical IR | page 45

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CONTENTS

June/July 2011 | Volume 4, Number 3

28

Features

28

The Great CT Bundling Heist of 2011

By George Wiley With the new CPT codes for combined CT exams of the abdomen and pelvis, the bundling of radiology escalates, and experts advise radiology to prepare for further abasement of the imaging codes.

45

The Lure and the Legend of Office-based Interventional Radiology

45

By Karen Roberts Although they encounter many obstacles, interventional radiologists continue to respond to the siren call of office-based practice, and some believe that the timing has never been better.

52

Performance Analytics: What Billing Can Tell You

By Felix Okhiria, MPA, MA, CCPO, CMPE, CPC, CHC Whether a practice uses in-house or outsourced billing, attention to key matrices will keep the organization on a profitable path.

37 The Top Five Medical Imaging IT Projects of 2010

4 Radiology Business Journal | June/July 2011 | www.imagingbiz.com

The winning entries in the 2010 competition are presented here.

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CONTENTS

June/July 2011 | Volume 4, Number 3 Publisher Curtis Kauffman-Pickelle · ckp@imagingbiz.com

Departments

8

EDitor Cheryl Proval · cproval@imagingbiz.com

AdView Your Undivided Attention

Art Director Patrick R. Walling · pwalling@imagingbiz.com

By Cheryl Proval

10

Technical Editor Kris Kyes

The Bottom Line

Associate Editor Cat Vasko · cvasko@imagingbiz.com

The Triple Threat of Bundling Codes

By Ezequiel Silva III, MD

12

Priors

12

Quality | A Dry Run for New Efficiency Measures

Informatics | The Plot Thickens on Meaningful Use for Radiology In Practice | Breast MRI: How I Read It

16

21

24 26

Online News Editor Julie Ritzer-Ross · jritzerross@imagingbiz.com

By George Wiley

Contributing Writers Ian Gardiner, MS; Felix Okhiria, MOA, ma, ccpo, cmpe, cpc, chc; Karen Roberts; Ezequiel Silva III, MD; George Wiley

By Ian Gardiner, MD

Reimbursement | The Other Data Deluge: ICD-10 Numeric | RBMs in New Orleans: The Panel and the Pain

58

Advertiser Index

60

Final Read

Online Editor Lena Kauffman · lkauffman@imagingbiz.com

Sales & Marketing Director Sharon Fitzgerald · sfitzgerald@imagingbiz.com Production Coordinator Jean Lavich · jlavich@imagingbiz.com Special Projects Coordinator Emily Kawka · ekawka@imagingbiz.com

Managing Expectations

By Curtis Kauffman-Pickelle

52

Corporate Office imagingBiz 17291 Irvine Blvd., Suite 105 Tustin, CA 92780 (714) 832-6400 www.imagingbiz.com PResident/CEO · Curtis Kauffman-Pickelle VP, Publishing · Cheryl Proval VP, Administration · Mary Kauffman

Radiology Business Journal is published bimonthly by imagingBiz, 17291 Irvine Blvd., Suite 105, Tustin, CA 92780. US Postage Paid at Lebanon Junction, KY 40150. June/July 2011, Vol 4, No 3 © 2011 imagingBiz. All rights reserved. No part of this publication may be reproduced in any form without written permission from the publisher. POSTMASTER: Send address changes to imagingBiz, 17291 Irvine Blvd., Suite 105, Tustin, CA 92780. While the publishers have made every effort to ensure the accuracy of the materials presented in Radiology Business Journal, they are not responsible for the correctness of the information and/or opinions expressed.

24 6 Radiology Business Journal | June/July 2011 | www.imagingbiz.com

Please address all subscription questions to Jean Lavich at jlavich@imagingbiz.com.

AdView

Your Undivided Attention The latest report from MedPAC to Congress tops the summer radiology reading list

T

he June 2011 report of the M e d i c a r e Payment Advisory Commission (MedPAC) to Congress1 probably has the undivided attention of the entire specialty, just days after its release—for good reason. Pages 27 through 59 detail the commission’s recommendations to curtail further the amount of imaging occurring in medicine and to redistribute professional income from image-reading specialties to primarycare practitioners.

There are some good ideas in the report, but there also are some bad ones.

For instance, a good deal of time is spent detailing how Medicare might build a rather complex preauthorization system to tide us over until new payment forms and delivery models remove the incentives to overutilize imaging.

Since we currently have a stimulus program that will lavish billions of dollars on health IT, doesn’t it make more sense to require computerized provider order entry (with built-in clinical decision support) for imaging than to build an expensive, overly complex legacy system to monitor outliers that would be obsolete within a few years?

Although the commission acknowledges that the growth in imaging slowed to 2% between 2008 and 2009 (and it probably slowed even further between 2009 and 2010), MedPAC believes that further efficiencies can be achieved by eliminating unnecessary exams. It appears to be gunning for negative growth.

Four Big Ideas

MedPAC makes four recommendations to reduce spending further on imaging— and this time, the professional component is on the table. Space constraints allow just a brief outline of those recommendations.

First, “The Secretary should accelerate and expand efforts to package discrete services in the physician fee schedule into larger units for payment.”1 MedPAC suggests that CMS consider lowering the bundling threshold a second time (it was just lowered from 90% to 75%), to include scrutiny of codes performed together less than 75%, but more than 50%, of the time.

Second, “The Congress should direct the Secretary to apply a multiple procedure payment reduction to the professional component of diagnostic imaging services provided by the same practitioner in the same session.”1 Why wait for the RVS Update Committee and its time-consuming scientific approach to pricing medical services? MedPAC says that CMS should consider an across-the-board reduction in the professional component (as recently enacted for the technical component) for studies performed for a patient, on the same day, by the same practitioner.

Reasoning that the physician gains efficiencies when he or she does not have to review the patient’s medical history, review the final report, and follow up with the referring physician twice, MedPAC suggests a discount on the second study. This makes sense, but may be difficult to apply to radiology workflow, since studies usually are routed by subspecialty and read as they show up in the radiologist’s queue.

One concern would be derailing the quality-improvement trend in radiology that supports the review of more information rather than less, including laboratory results, physician notes, and other information in the electronic medical record. An unintended consequence of reducing professional rates could be the discouragement of an expanded consulting role for radiologists.

Third, “The Congress should direct the Secretary to reduce the physician work component of imaging and other diagnostic tests that are ordered and performed by the same practitioner.”1 Throughout its report, MedPAC underscores the relationship between self-referral and overutilization, but confesses to a reluctance to tighten the in-office ancillary exception because it does not want to constrain accountablecare organizations—when (and if ) they ever materialize—from including imaging.

What it does propose is to discount imaging reimbursement for practitioners who both order and interpret an exam, to account for the efficiencies gained in not having to review the patient’s medical history (since that took place during the office visit), review the final report, and follow up with a referring physician. This makes sense.

Fourth, “The Congress should direct the Secretary to establish a prior authorization program for practitioners who order

8 Radiology Business Journal | June/July 2011 | www.imagingbiz.com

substantially more advanced diagnostic imaging services than their peers.”1 MedPAC recommends instituting a priorauthorization program for outliers who fail to change their behavior after participating in a prior-notification program.

Only those physicians who are identified as overutilizers would be required to participate, although MedPAC acknowledges the difficulty of adjusting the averages to account for differences in population. It also suggests that providers could use a decision-support system, if it syncs with the appropriateness criteria used by CMS. Even though the Patient Protection and Affordable Care Act mentions use of a radiology benefit management company, MedPAC notes that Congress will have to enact legislation to ensure the constitutionality of the program.

MedPAC projects that the program could save under $50 million in the first year and less than $1 billion over 5 years, including the cost of developing and managing a prior-authorization process.

In the months and years ahead, radiology will need to do its part to help Medicare shave costs by submitting to appropriate reimbursement adjustments, but radiologists owe it to their specialty to ensure that those adjustments are reasonable. Today, however, radiology has arrived at a defining moment: It is now or never.

What are you going to do to take control of the overutilization problem? If radiologists had been willing to accept the responsibility for imaging appropriateness rather than worrying about alienating referring physicians, then MedPAC might be talking about gutting a different specialty.

cproval@imagingbiz.com

Reference 1. Medicare Payment Advisory Commission.

Report to the Congress: Medicare and the Health Care Delivery System. http:// www.medpac.gov/documents/Jun11_ EntireReport.pdf. Published June 15, 2011.

Accessed June 20, 2011.

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The Bottom Line

The Triple Threat of Bundling Codes CMS policies concerning misvalued codes have ushered in a new period of uncertainty for radiology

R

adiology’s existing coding structure is undergoing a dramatic transformation, which is the product of numerous code screens being used by CMS and the RVS Update Committee to identify potentially misvalued services. The application of these code screens often results in the conversion of old codes to new codes. The conversion to new codes has significant implications for radiology services because the new codes are subject to a complete revaluing.1 Revaluing triggers a cascade of effects resulting in what I call the triple threat of bundling. The triple threat has two layers. It causes immediate reductions in professional-component, technical-component, and hospital payments. In addition, the triple threat (on a more general level) has three consequences: payment reductions in all three service components, lack of a transition period for upcoming technicalcomponent reductions, and a relatively short time between notification and implementation.

Payment Reductions One of the screens used to identify potentially misvalued services is that of procedures frequently reported together.

This screen provides an illustration of the effects that these screens can have on payment. The usual course of action for codes that are frequently reported together is to bundle the codes, based on the assumption that efficiencies occur when these services are performed together.

Accordingly, the new bundled codes often cause reductions in their professional-component and technicalcomponent RVUs, compared with the values for the old individual codes. For example, when CT exams of the abdomen and pelvis were bundled, the outcome was a sharp reductions in value. These reductions are not limited to Medicare, since private-payor contracts can be linked to the Medicare Physician Fee

by ezequiel silva iii, md

Schedule. Moreover, private payors might request completely renegotiated payment rates for these revised codes.

Hospitals are paid under the Outpatient Prospective Payment System (OPPS) and also experience reductions when codes are revised. A service’s Ambulatory Payment Classification (APC) determines payment in the OPPS schedule. In the case of CT exams, when more than one is performed at the same time, those combined services are assigned to higher-paying composite APCs. When CT exams of the abdomen and pelvis were bundled, CMS ignored the fact that the bundled codes actually represent more than one service; it placed the bundled codes into the same APC as the individual abdominal and pelvic CT exam codes.

Consequently, payment to hospitals for the same services is decreased.

CMS recently began using updated data from the Physician Practice Information Survey (PPIS) in the formula that it uses to determine technical-component payment. Because the PPIS data resulted in significant technical-component reductions for radiology, CMS agreed to phase in the reductions over four years (2010–2013).

CMS refused, however, to phase in the cuts to the revised codes, ignoring the fact that these bundled codes actually represent existing services. As such, the revised codes suffered larger immediate reductions than existing codes. For that reason, the global payments for the individual codes for an abdominal CT exam and a pelvic CT exam (transitioned over four years) are essentially the same as the payment for the new bundled codes (not transitioned).

radiology groups could be forced to adjust their revenue and salary estimates, based on the lower rates of payment. Further, business managers must decide how services reported the year before (using old codes) will be reported during the next year (using new codes).

For CT exams of the abdomen and pelvis, for example, how many times were these exams performed together under the old system, and how does this translate to reporting these services using the new bundled codes? What effect will this bundling of services have on revenue from these services and on overall revenue?

From the technical-component side, revenue projections for new-equipment purchases were probably derived from the previous year’s payment rates. Therefore, adjustments to these projections might be necessary (using the new technicalcomponent values).

Medicare’s trend of bundling existing codes into new codes is having significant effects on radiology’s code structure and on payment for radiology services. Numerous existing codes will be bundled together, resulting in reductions in professionalcomponent, technical-component, and hospital payments.

To make things worse, business managers are essentially in the dark on the specific codes being revised—and on those codes’ payments—until the last quarter of the year preceding implementation.

This bundling trend will continue for the foreseeable future, and radiology groups and hospitals should plan for the cuts that will follow.

Limited Notification

Ezequiel Silva III, MD, is the director of interventional radiology and treasurer for South Texas Radiology Group in San Antonio, is chair of the ACR® practice-expense subcommittee, and is an ACR RVS Update Committee advisor; zeke@zekesilva.com.

Revised codes and their reduced RVUs are not made available until October of the year preceding implementation. In other words, radiology groups will have less than three months to plan for the reductions that will follow publication of the new codes. This presents challenges in planning an organization’s budget and capital expenditures for the next year.

From the professional-component side,

10 Radiology Business Journal | June/July 2011 | www.imagingbiz.com

Reference 1. Silva E. New codes from a new source: the rolling five-year review. J Am Coll Radiol.

2010;7(1):10-12.

Arm in arm.

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A Dry Run for New Efficiency Measures

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dry run that CMS is conducting for three new outpatient imaging efficiency (OIE) measures that the agency will implement in 2012 is now underway. It uses Medicare’s fee-for-service hospital outpatient data from 2009. The dry run is a practice round offering hospitals an opportunity to assess their ordering patterns for the designated imaging exams and to rank themselves against other hospitals according to the frequency with which the exams are conducted. The dry-run data will also let hospitals spot outlier physicians who might be ordering too many of the tests.

Neither the dry run nor the efficiency measures will affect reimbursement directly, but CMS notes that there is a financial aspect to the introduction of the new outpatient imaging reports.

If hospitals fail to report on the new imaging standards (beginning in 2012), they could lose a 2% compliance bonus added to annual payment updates.

The dry run is designed to get the bugs out of the real reporting that will be required in 2012. It was kicked off in April 2011 with a webinar conducted through the Lewin Group (Falls Church, Virginia), a CMS consultant on the OIE project.

The Lewin Group is also consulting on the Medicare Imaging Demonstration, a

By George Wiley

project that CMS is conducting to test the utility of computerized decision support in the ordering of advanced imaging exams.

The Lewin Group’s physician expert for the webinar on the imaging-efficiency dry run was Michael Pentecost, MD. A radiologist, Pentecost is a former director of the ACR® Institute for Health Policy in Radiology; he currently serves as CMO for National Imaging Associates (NIA), Avon, Connecticut, a radiology benefit management company. NIA is also one of five conveners named to conduct the Medicare Imaging Demonstration for CMS. Placed in the larger context, the Medicare Imaging Demonstration and the three new OIE measures on which hospitals will have to report next year are part of a CMS effort to control Medicare’s imaging expenses by focusing on efficiency in the ordering and imaging process, as well as on appropriate use of tests.

CMS is also cutting reimbursements through bundling the reimbursements for some exams. One of the new exams for which CMS wants an OIE report is a simultaneous brain and sinus CT exam, which has apparently not been bundled, but which is typical of the dual exams that have been combined thus far. The CMS goal for the new brain and sinus CT OIE is to restrict the procedure to a head CT exam and expand it to include a sinus CT exam if needed, based on a subsequent diagnosis.1 The Right Test, Patient, and Time CMS has adopted the ACR’s mantra of performing the proper test, for the proper patient, at the proper time. In addition to efficiency, a CMS concern is holding down radiation exposure for patient safety. Alan Friedlob, PhD, a Lewin Group project manager who led participants through the OIE webinar, says that CMS had

12 Radiology Business Journal | June/July 2011 | www.imagingbiz.com

selected the new OIE measures based on their importance, usability, feasibility, and adherence to evidence-based medicine and practice guidelines.

“Using that driver, we look at measures to promote high-quality, efficient care, where the goal is to reduce the overuse of clinical services that may have negligible benefit for the patient,” Friedlob says.

OIE measure reporting for hospitals under the CMS Outpatient Prospective Payment System was mandated under a 2009 CMS final rule. The initial set of imaging quality-control measures applied to certain MRI, CT, and mammography exams. This year, three new measures were added; these are the measures used in the current practice run for reporting.

They are designated OP-13, OP-14, and OP-15.

OP-13 is cardiac imaging prior to low-risk surgery. According to the dryrun mock report,1 cardiac imaging is common for Medicare recipients; in 2008, more than 750,000 cardiac-imaging stress tests were performed for Medicare outpatients. From 1998 to 2006, the number of myocardial-perfusion tests conducted by cardiologists in a hospital setting for Medicare patients grew 51%.

Across all settings, myocardial-perfusion testing increased 227%, with in-office use increasing 215%.

Pentecost says that OP-13 was intended to look at those patients undergoing noninvasive stress tests (SPECT myocardial-perfusion tests, stress MRI exams, or stress echocardiograms) within 30 days prior to undergoing lowrisk noncardiac surgery. Low-risk surgery was defined as having less than a 1% chance of cardiac complications during or following the surgery.

“There is agreement that these patients don’t need cardiac screening with these tests,” Pentecost says. More than 200 lowrisk surgeries, many of them endoscopic

or superficial (such as cataract surgery or breast surgery that could be performed in an ambulatory outpatient setting), were placed in this category. Patients tested without need are unnecessarily exposed to radiation, Pentecost notes.

For SPECT myocardial-perfusion tests, he says, the radiation exposure is high (around 15 mSv per exam). This exam already accounts for over 22% of the total radiation-exposure burden, and its use is growing rapidly, Pentecost says.

OP-14 is a simultaneous CT exam of the brain and sinuses. Radiation exposure was a concern with OP-14, since it is a procedure that CMS considers duplicative, in many cases, according to Pentecost. “The important issue is the radiation issue,” he says, explaining that the radiation dose for the combined exam is roughly 100 to 200 times the equivalent of the dose for chest radiography.

Pentecost says that it is generally agreed that because the sinuses can be seen on a brain CT exam, a sinus CT is not needed, in most cases. He adds that there are important exceptions, however, including patients with head trauma, who might need facial-bone CT as well as cranial CT; patients who have a tumor of the brain or sinuses, with extension from one region into the other; and patients with orbital cellulitis or an intracranial abscess. All are legitimate candidates for simultaneous brain and sinus CT exams.

These patients are to be excluded from the OP-14 reports, Pentecost notes.

“What we want to make sure of is that hospitals that participate in this kind of effort do not perceive any obstacles to care,” he says. “Certain patients may need both exams, and we want to exclude them from the study so that there’s no perception that they aren’t getting the necessary care.”

OP-15 is a brain CT exam in the emergency department for atraumatic

headache. According to Pentecost, a common pattern, in emergency departments, is to order a head CT exam for outpatients complaining of headache— even stress headache. This is often done to save time and streamline patient flow in the emergency department. This results in unnecessary head CT studies for patients who have no evidence of head trauma.

These unnecessary head scans also increase radiation-exposure levels.

Pentecost notes a long list of conditions, however, in which a head CT might be called for in atraumatic headache in the emergency department. These include recent lumbar puncture, dizziness, paresthesia, lack of coordination, possible subarachnoid hemorrhage, HIV infection, and other evidence of pathology of the central nervous system. Patients with these conditions, as well as outpatients with headache who are subsequently admitted to the hospital, are not to be included in the OIE reporting, Pentecost says.

The Reporting Process Friedlob says that it is not necessary for hospitals to compile their own data. CMS has already compiled the data using feefor-service Medicare outpatient imaging claims from 2009, the exemplary period to be used in the dry run. These dryrun data will not be publicly reported, Friedlob says.

To begin the dry run, a hospital needs to obtain its individual, confidential hospitalspecific report (HSR) from CMS. This is available through www.qualitynet.org at a secure portion of the site that is accessible using the My QualityNet tab. There, a hospital representative can enter the facility’s provider number and use the send/ receive tab in the Exchange Files section to reach its individual inbox. The HSR will be shown in the files-received list.

Accompanying the HSR will be a separate report with patient-level data,

Friedlob says. These data, which must be kept private under federal regulations, will show limited patient information for those patients in the numerator portion of each OIE measure. The numerator portion of OP-14, for instance, would be those patients who were given simultaneous sinus CT exams and brain CT exams. The denominator would be all the patients given a brain CT exam.

Along with its HSR data, each participating hospital will be given national data and charts that CMS has compiled for the three new OIE measures.

These will let the hospital compare itself with national datasets for the same OIE. The hospital can also use the dry-run data to determine whether it meets minimum case counts for reporting, Friedlob says.

The dry run will give hospitals time to respond to CMS with any concerns that they have about the new OIE measures.

Do they understand how the data were compiled? Do they agree with the criteria used in the three OIEs? “Is the measure meaningful, understandable, and useful for quality improvement? How well defined are the specifications? Are they detailed enough and standardized enough? That data feedback is critical,” Friedlob says. The Lewin Group will issue a report on the dry run, to be shared with CMS, later this summer. The real reporting starts next year.

George Wiley is a contributing writer for Radiology Business Journal.

Reference 1. QualityNet. Outpatient imaging efficiency measures—OP-13, OP-14 and OP-15. https://www.qualitynet.org/dcs/ ContentServer?c=Page&pagename=Qnet Public%2FPage%2FQnetTier2&cid=120 5442110963. Published April 20, 2011.

Accessed June 12, 2011.

www.imagingbiz.com | June/July 2011 | Radiology Business Journal 13

CASE STuDy Shifting from in-house billing to outsourcing significantly reduces denials and cost of collections for Atlantic Medical Imaging In the ever-evolving world of radiology billing, Atlantic Medical Imaging (AMI) has found a steady solution in Zotec Partners.

The core values of the leading New Jersey imaging group include integrity, clinical excellence, compassion, service and care—its patients come first.

Atlantic Medical Imaging is a full service, outpatient imaging practice operating eight offices throughout New Jersey and providing professional services to three area hospitals. With 38 board-certified radiologists and a staff of 350 technical, clerical and administrative personnel, AMI has been committed to providing the most advanced diagnostic imaging services to patients and referring physicians for more than 40 years.

But no business can run smoothly and successfully without closely monitoring its revenues and costs, and this is especially true of medical practices. That’s where medical billing leader Zotec Partners comes in.

Through its comprehensive medical billing and practice management software and services, the company enables AMI to adhere to its core standards while maximizing efficiency and collections.

“The biggest advantage of partnering with Zotec is knowing that the revenue cycle is in expert hands,” said Dr. Robert M. Glassberg, president and CEO of Atlantic Medical Imaging In May 2009, AMI licensed Zotec Partners’ Electronic Billing Center (EBC) software in an effort to keep billing in-house, reduce costs and capitalize on the potential for revenue. In less than a year, the group realized that collections performance was not being maximized by its internal billing staff of 25 employees. In May 2010, AMI turned billing completely over to Zotec Partners—proven medical billing specialists with a long history of success in maximizing reimbursement.

Today, Zotec Partners ensures that AMI can focus on its clinical care and not worry about the bottom line. Capturing, auditing and processing every procedure to maximize income is now Zotec Partners’ responsibility.

“The biggest advantage of partnering with Zotec is knowing that the revenue cycle is in expert hands,” said Dr. Robert M. Glassberg, president and CEO of Atlantic Medical Imaging, who has recommended Zotec’s trusted software and services to colleagues.

The Challenge: Missing Industry Benchmarks; Performance Problems A dizzying array of consumer-driven health insurance plans, including health savings accounts (HSAs), can bury any practice under an avalanche of medical billing paperwork.

Zotec Partners. The total solution.

Obtaining every collectible dollar at a lower cost of billing is the goal— not an easy task for practices like AMI that read more than 500,000 exams each year.

“Prior to outsourcing our billing, the standard metrics used in the revenue cycle industry were falling well below industry benchmarks,” said Glassberg. “Our key performance indicators showed the need for improvements in our accounts receivables management.”

This issue was magnified by AMI’s own performance issues.

“When doing our own billing, we faced some performance problems,” said Glassberg. “Then, as we compared rebuilding our internal billing operations against outsourcing them altogether, the latter option with Zotec Partners was our best choice.”

That is not to say, however, that it was an altogether easy choice.

AMI did its due diligence to thoroughly evaluate Zotec Partners before entrusting the group to implement a comprehensive solution for consistent and cost-effective improvements in billing reliability.

“I checked references and talked with several of Zotec Partners’ clients,” said Glassberg. “I could see that they understood the industry and I felt comfortable with them.”

Any missed bill translates into AMI’s physicians working for free. While Zotec’s EBC software contains radiology-specific coding to ensure accuracy and optimum payment for the work that is completed, the Radiology Information System (RIS) allows the most efficient process flow for the practice.

“We pulled off the transition and did so without any significant drop in cash, which is always a concern,” said Glassberg. “A technology shift as big as this one is not the easiest thing to pull off without any hitches, but I have to say, the transition went as planned. Zotec gave us a timetable and said it would happen on a specific date and that timetable was met. From my standpoint, it did go well.”

“We use the RIS for scheduling and registration 100 percent of the time,” said Glassberg. “It has become an integral part of our work flow.”

Zotec’s RIS is resource-based and template driven, allowing it to effectively manage AMI’s practice scheduling and workflow needs.

Features available with just a few clicks of a mouse include the ability to overbook, block and reschedule appointments.

Other benefits include the ability for AMI to create unlimited resource templates, collect patient co-pays, update demographics and scan

patient information. And because the software is integrated with the EBC, users receive notifications regarding the status of a patient’s account before scheduling exams.

Most importantly—denials are down to the single digits on a monthly basis.

“We attribute the drastic decrease in denials to a combination of the efforts of our managers and Zotec’s powerful billing solution,” said Glassberg.

In addition, Zotec Partners’ Decision Support software has been another key tool for AMI. The reporting technology allows the group to drill down into its business information for data mining and analysis purposes— giving it a rock-solid platform and scientific approach in making critical business decisions.

“The Decision Support module is very robust and has allowed us to make more data-driven decisions, whereby previously we made more gut driven decisions,” said Glassberg.

In addition to the numerous benefits of its technology offerings, Zotec was there when it mattered most for AMI; ensuring the transition from in-house to outsourcing was a smooth one—a testament to its customer service.

The Results: Cost Savings; Fewer Denials Fast forward from May 2010 to present day 2011. The result of outsourcing to Zotec Partners has been lower overhead and increased payments for AMI—a prescription for financial success for any practice.

AMI’s billing staff has been reduced from about 25 individuals, or an entire department, to one full-time billing employee and less than five additional employees overseeing the process.

“Performance is certainly an improvement from the internal problems we previously were having, which drove us to make a change in the first place.”

But the biggest advantage with outsourcing its billing has come in cost savings at the practice, allowing AMI to focus on one of its core values: clinical excellence.

“There’s little doubt in my mind that we are spending less to collect payment than what we previously were—our percentage of revenue assigned to billing has gone down significantly,” said Glassberg.

“Performance is certainly an improvement from the internal problems we were having, which drove us to make a change in the first place. We have realized a big savings on the cost side, and that’s very important for any group in this era of declining reimbursement.”

P 317.705.5050 11460 N. Meridian St. F 317.705.5047 Carmel, IN 46032 sales@zotecpartners.com zotecpartners.com

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i n f o r m at i c s

The Plot Thickens on Meaningful Use for Radiology

T

here is bad news and good news for radiology, when it comes to meeting meaningful-use requirements, according to Keith Dreyer, DO, PhD, vice chair of radiology computing and information sciences at Massachusetts General Hospital (MGH) in Boston. In the Dwyer Lecture, “Meaningful Use in Medical Imaging: New Technologies for US Healthcare Reform,” which he presented at the 2011 meeting of the Society for Imaging Informatics in Medicine on June 3 in Washington, DC, Dreyer began by debunking certain meaningful-use myths.

These myths were that radiologists have somehow been singled out by the regulations, that the stage 2 requirements have already been released, and—most important—that there’s a chance that radiology will not have to deal with meaningful use at all. “That’s not the case,” Dreyer says. “This is not going to go away. We need to get more and more involved, rather than burying our heads in the sand.”

The misconception that radiology might somehow be exempted from the requirements dates back to the original Health Information Technology for Economic and Clinical Health Act, Dreyer says, which appeared to exclude the specialty. In April 2010, however, the Continuing Extension Act of 2010 mandated a change to the requirements that brought radiology back into the fold.

By revising the original definition of hospital-based eligible professional to include hospital-based physicians practicing in outpatient settings, the legislation rendered over 90% of radiologists eligible for meaningful-use certification. “It looked like this wasn’t going to involve us,” Dreyer notes, “until the second law was passed.”

Now that the vast majority of radiologists are clearly eligible, one area of confusion among both hospital-based radiologists and their colleagues is whether radiologists are eligible professionals or part of eligible hospitals. Dreyer says that the former is almost uniformly the case. “You’re part of an eligible hospital if 90% or more of your practice is in an

inpatient hospital or emergency department. What is the chance of anyone in your group having 90% of interpretations from Keith Dreyer, DO, PhD coming inpatient or emergency-department visits?” he asks.

Radiologists should start taking pains now, he urges, to explain this to those within their hospitals whose support they might need as they move forward. “Help your hospital CIOs understand that you are eligible professionals,” he advises.

Another contentious subject is that of how radiologists should prepare to meet the stage 1 requirements laid out by CMS. Dreyer explains that according to the Office of the National Coordinator (ONC), modular certification is an option for vendors—meaning that applications like RIS can attain modular certification—but there is no corresponding modular option for radiology and other specialties.

“You can exclude yourself from some of the requirements and opt out of others,” he says, “but you still have to possess the technology to

16 Radiology Business Journal | June/July 2011 | www.imagingbiz.com

do all of the other things (even if you don’t use it) to meet your meaningful-use measures. I have to have the ability to do immunizations, even though I never will.”

Steps to Radiology Meaningful Use Since there is no way out of or around meeting the requirements, Dreyer outlines four steps for radiology practices to take to achieve meaningful use. Step 1 is consideration. Practices should make sure that they understand the fundamentals of meaningful use, he says, and should determine both their eligibility and the potential financial impact of the program.

Tools available free at www.radiologymu. org can assist with both analyses.

Step 2 is preparation. Groups should assemble their stakeholders and initiate planning conversations with the IT staffs of their groups and/or hospital. They should also meet with their radiology IT vendors to assess what their plans are for meaningful-use certification.

Step 3 is execution. The most important goal, at this phase, is maintaining

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Allen Rothpearl, MD Founder, Complete Radiology Reading Services Organized the digital transmission of images from a pediatric hospital in Haiti to CRRS after the devastating earthquake in 2010.

Dr. Rothpearl and his associates read the examinations and donate their interpretations to the hospital to this day.

Allen Rothpearl uses eRAD PACS.

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it is simply the right thing to do.”

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Imaging Market File

Cost Comparison: Hospital-based Versus Freestanding Outpatient Imaging Services

A

Sponsored Supplement

s the imaging marketplace considers the move toward more costefficient delivery of high-quality imaging, understanding and comparing where the two major imaging market segments stand, relative to the cost of delivery, has bearing on both profitability and accountability.

Introduction: This second installment of the Imaging Market File quantifies the cost variance between hospitals and freestanding centers by comparing four major Staff and benefits cost: For hospital calculations, staff and benefits costs generally include clinical personnel related to delivering imaging services (technologists, nurses, and technologist aides). Administrative personnel and physicians have not been included in the data, as they are typically allocated as overhead expenses that cannot be attached to any one service line or modality.

For freestanding imaging providers, staffing costs are usually not broken out between clinical and administrative functions. Regents Health Resources (Franklin, Tennessee) used its knowledge of staffing levels, compensation, and benefits at various facilities and, based on volume, determined that the average staff expense for freestanding imaging providers is split 70% for clinical staff and 30% for administrative staff. These percentages were applied to any facility that did not provide delineated clinical and administrative staff cost data.

Supply cost: Supply costs reflected in these data are directly related to volume and are therefore variable, based on exam volume. Factors affecting a providerâ&#x20AC;&#x2122;s ability to have an impact on supply costs include purchasing power (either through group purchasing organizations or corporate supplier agreements), exam mix, physician preferences and protocols, and overall staff efficiency.

In addition, freestanding imaging facilities typically do not break out supplies by modality. Advanced imaging, however, tends to have higher supply costs; therefore, Regents Health Resources used revenue by modality as a means of assigning supply costs to each service. The supply costs are variable based on volume and are allocated based on revenue.

direct-expense lines in imaging operations: staff benefits and costs, supply costs, depreciation, and other direct costs. This by no means represents the total cost of operating imaging services. This analysis does not include indirect costs, such as facility costs, administrative costs, and imaging IT hardware and software.

These results (Figures 1â&#x20AC;&#x201C;4) represent a total of 55 unique locations (33 hospitals and 22 imaging centers), more than 2.3 million exams, and nearly $1 billion in revenue during 2009 and 2010.

$190.02 MRI

$75.82 CT

Radiography

Ultrasound

$62.25 $68.57 $64.43

Mammography

$366.58

Nuclear Medicine

$752.39

PET

Figure 1. Average expenses per procedure, by modality, in the hospital setting.

$137.50 MRI

$101.94 CT

Radiography

Ultrasound

$39.69 $51.54 $56.29

Mammography Nuclear Medicine

$130.87 $405.44

PET

Figure 2. Average expenses per procedure, by modality, in the freestandingâ&#x20AC;&#x201C;imaging-center setting.

June/July 2011

Imaging Market File

Depreciation cost: Depreciation generally refers to an accounting concept that provides for the reduction in value of an asset or the partial use of an asset over time. In determining the net income from an operation, the assets and their associated cost of use must be considered. Depreciation provides a method for calculating the usage cost of an asset, to be spread out over its usable lifetime (rather than considered all at once). It allocates a portion of the cost of an item to each year that the asset helps generate income. Depreciation terms for imaging equipment typically range from five to seven years, based on the apportioning methodology used in accounting.

It is possible to depreciate an asset completely, yet keep the asset in operation, thereby reducing the depreciation-expense line item. The total depreciation-expense line could be interpreted as a gauge for an organizationâ&#x20AC;&#x2122;s ongoing investment in technology or facilities.

Other direct costs: Several categories of expenses are represented here. It is important to note that freestanding imaging operators can most often quantify the cost of the facility, whereas hospital-based imaging operations see an allocationexpense line item that encompasses many items to account for the overhead needed to support imaging as part of a much larger organization. Therefore, in order to present a more accurate comparison, any rent or space allocations were removed from both datasets, as were office expenses and general administrative costs. Repair and maintenance costs for equipment are included, but PACS costs are not, due to the variability of delivery and cost models.

Summary statement: When comparing the average expenses per procedure of hospitalbased outpatient imaging and freestanding outpatient imaging, freestanding sites appear to be performing all modalities more cost-effectively, even with administrative

minimum

$14.81

Salaries and benefits

average

$42.77

maximum

$119.04

minimum Supplies

$2.31 average $11.90

maximum

$89.16 minimum Other expenses

$5.08

average

$32.94

maximum

$120.88 minimum Depreciation expense

$3.57

average

$24.47

maximum

$99.68

Figure 3. Expenses per procedure for each direct-cost category in the hospital setting, including minimum, maximum, and average costs. minimum

$14.38

Salaries and benefits

average

$35.83

maximum

$77.58 minimum Supplies

$1.60 average $8.87

maximum

$23.99 minimum Other expenses

$0.35

maximum

average

$91.07

$21.55 minimum

Depreciation expense

$4.16

average

$19.35

maximum

$80.41 Figure 4. Expenses per procedure for each direct-cost category in the freestandingâ&#x20AC;&#x201C; imaging-center setting, including minimum, maximum, and average costs.

Average expense, hospital:

$85.78

Average expense, imaging center:

$69.33

and facility costs removed to normalize both settings.

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radiologists’ productivity, Dreyer stresses.

“If needed, consider acquiring additional technology,” he says, “and you need a dashboard view of measure compliance to make sure you’re hitting those thresholds before you attest.”

Step 4 is compliance. Registration for the program can be completed online at www.cms.gov/EHRIncentivePrograms /20_RegistrationandAttestation.asp, and large practices are now permitted to sign up via single administrator. Dreyer describes online attestation as pretty straightforward, and a sample attestation calculator is provided at www.cms.gov/ apps/ehr. Documentation of the process must be maintained for six years.

The Upside Though the requirements are burdensome in the short term, the news isn’t all bad, Dreyer says. To begin with, at a maximum of $44,000 per eligible professional through 2015, the incentive bonuses offered by CMS have the potential

to add up quickly. In a seven-year financial go/no–go analysis performed by MGH, the hospital discovered that its eligible hospital incentives would add up to $42 million, while its incentives for eligible professionals, including radiologists, added up to $58 million. “That’s $100 million in seven years for a typical large academic medical center,” Dreyer says.

Special provisions for radiology and other specialty areas of medicine might also be in the offing, he adds.

Just two days before his talk, the ONC meaningful-use working group indicated that it would submit a separate set of recommendations for specialists, with the understanding that the one-size-fits-all approach to the eligible-professional side of the regulations is not working.

“They said they will send another recommendation that includes specialty issues—and specifically, medical imaging—in approximately two months,” he says. “It’s very encouraging that they’re seeing that they have to

address medical imaging to have a really complete electronic health record (EHR) meaningful-use solution.”

Dreyer, who recently testified to the working group, hopes to see the ONC requirement for possession of all certification criteria removed for radiologists, and he wants the definition of radiology results expanded to include images, as a move toward promoting image sharing and distribution via EHR. In the meantime, he calls for radiology groups to see the meaningful-use program as an opportunity, rather than a burden.

“You need to be thinking constantly about what you need to do to make your practice better, because that’s what the federal government is telling us to do,” Dreyer says. “There’s going to be more and more pressure coming from the government to us through accountablecare organizations, meaningful use, and more, so it’s in your best interest to understand this.”

—Cat Vasko

in practice

Breast MRI:

B

How I Read It

reast MRI has emerged as a powerful new tool in the fight against breast cancer. It has found wide acceptance in the past 10 years, and it appears to be one of the most rapidly growing medical studies.

When breast MRI is combined with mammography and breast ultrasound, we are now able to find breast cancer at its earliest stages, when the disease can be treated most easily and successfully.

Unlike conventional mammograms and sonograms, which might generate a dozen or so images per patient, breast MRI creates 2,000 or more. This has created much additional work-up activity for clinic- and hospital-based radiologists, who are already very busy (and in short supply). The growing demand for breast MRI, combined with the stagnant supply of radiologists, created a need for new

By Ian Gardiner, MD

tools that would boost the efficiency of radiologists; enter computer-aided detection.

Computer-aided detection streamlines the radiologist’s workflow by automating several time-consuming tasks. First, it processes the raw data to correct for any movement that has occurred during the study, eliminating artifacts from motion.

Second, it organizes the images into the radiologist’s preferred hanging protocol, so that the most relevant images are displayed initially.

Third, it analyzes the images to find the areas of tissue that have the most abnormal blood supply (an important sign that can indicate the presence of cancer). Fourth, it simplifies generation of reports, making use of ACR® BI-RADS® terminology.

A typical case will demonstrate

some of the ways that I use computeraided detection. I begin my analysis by looking at the patient’s requisition and other paperwork. It is important to understand why the patient is having a breast MRI exam. Potential reasons include assessment of breast implants, determining the true extent of disease in a newly diagnosed breast-cancer patient, and looking for evidence that treatment is effective. I also review any previous imaging that the patient has undergone, including prior MRI studies, mammograms, and breast sonograms.

Next, I turn to my monitor and bring up the maximum-intensity projections (Figure 1). These 3D images have been reconstructed, using computer-aided detection, from the raw data. They allow me to have a global view of the breast tissue from a variety of different angles.

www.imagingbiz.com | June/July 2011 | Radiology Business Journal 21

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Figure 1. Maximum-intensity projection showing recurrent breast cancer near the chest wall.

Figure 2. High-resolution axial image showing recurrent breast cancer near the chest wall.

Once I have the sense of the lay of the land, I go to the next step in my hanging protocol. These are the various highresolution cross-sectional images that I use to analyze the anatomic characteristics of any lesions (Figure 2). Computer-aided detection includes a number of tools to assist me in my analysis.

With one click, the software can determine precisely where a lesion is located, measure its size, and calculate its distance from various landmarks, such as the chest wall and skin surface. This information is automatically added to the report. I can also select key images that demonstrate particular features of the lesions. These images can be saved to an external device that I can then take to rounds or tumor boards.

In most instances, the high-resolution images give sufficient information to help me decide whether a given lesion is worrisome or not. At other times, I must turn to the so-called kinetic images to help me form an opinion. Kinetic images (Figure 3) can be thought of as time-lapse photography, demonstrating the flow of gadolinium dye through the breasts. This dye tends to accumulate in cancerous tissue.

We look at a variety of parameters to help distinguish between normal and suspicious tissue, including how rapidly blood flows into and out of the area of concern. These calculations are tedious when done manually, but can be rapidly and accurately done by the computer. The software generates color maps that can be superimposed on the anatomic images to highlight the areas of greatest concern.

You can think of this as being like a spell checker for a document: It draws the radiologistâ&#x20AC;&#x2122;s attention to those areas that might require further evaluation.

After I have completely characterized the lesion, I turn my attention to the areas where breast cancer can spread. These include the axilla, skeleton, and liver.

Along the way, I can add particularly important images directly to the report.

Now that I have completed my interpretation of the images, all that is left for me to do is to dictate a brief summary of the findings, an overall assessment of my level of suspicion, and my recommendations for followup care. These might include additional imaging, a biopsy, or a return to screening mammography. Then, itâ&#x20AC;&#x2122;s on to the next case.

22 Radiology Business Journal | June/July 2011 | www.imagingbiz.com

Figure 3. Graphical representation of the blood-flow pattern through the tumor over time.

Ian Gardiner, MD, is breast-imaging director of Canada Diagnostic Centres in Vancouver, British Columbia; is clinical assistant professor in the University of British Columbia department of radiology; and is a breast-imaging consultant at the Specialist Referral Clinic, Vancouver. He sits on the board of the Canadian Breast Cancer Foundation (British Columbia and Yukon chapter).

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reimbursement

The Other Data Deluge: ICD-10

I

n his preview1 in Health Affairs of the impending data deluge scheduled to begin with the transition to ICD-10 on October 1, 2013, Harris Meyer explains that the international diseaseclassification system dates back to 1763, when—in an act of altruism toward his fellow physicians—Francois Boissier de Sauvages de Lacroix (1706–1767) published a list of 10 major classes of diseases and 2,400 individual diseases.

When the adoption date rolls around in 2013, it is unlikely to be greeted by radiologists—or their coders and billing companies—as an act of altruism. The number of diagnostic codes will jump from 16,000 to 69,000; the number of procedure codes that can be performed on an inpatient basis will jump from 3,800 to 72,000, affecting every aspect of clinical and business operations.

The first International List of Causes of Disease was jointly adopted in 1898 by Canada, the United States, and Mexico, while other countries developed their own lists, some with morbidity listings.

The modern ICD got its start in 1948, when the World Health Organization (WHO) took over responsibility for disease reporting and published its first International Statistical Classification of Diseases in 1949: ICD-6. The system provided a framework for tracking and understanding disease trends worldwide and was updated every 10 years.

In 1976, WHO issued ICD-9, the version still in use in the United States (though other countries began adopting ICD-10 as early as the 1990s). Many countries, including the United States, developed their own versions, raising concerns that the system will be less useful in tracking world health trends, moving forward. The US version is by far the most complex, with 69,000 separate codes; Australia’s has 16,000, and Germany’s has 13,000.

The new level of detail contained in ICD-10, however, has the potential to confer many benefits. For instance, ICD-9, Meyer writes, lacked enough granularity to support the move to valuebased purchasing, which requires a more

precise accounting of appropriateness and intensity. ICD-10 also has the potential to aid fraud enforcement by improving the ability to spot mismatches between diagnoses and procedures.

The DHHS believes that ICD-10 will improve efficiency by reducing claims rejections by insurers and by facilitating the identification of patients with chronic conditions.

Significant Change Beyond the changes required of physicians, coders, and billing personnel in adapting to a new disease classification that has more than a fourfold increase in diagnostic codes and an 18-fold increase in procedure codes, the new system features structural changes that will require big adjustments on the part of providers and payors, Meyer forewarns readers.

First, ICD-10 makes procedure codes separate entities, called ICD-10-PCS. Second, ICD-10 codes are not only alphanumeric, but also several digits longer: three to seven digits instead of three to five for diagnostic codes and seven digits instead of three for procedure codes. Third, there is a very low rate of matching between ICD-9 and ICD-10 codes for similar procedures.

CMS has published general equivalency maps linking similar codes in the two versions, but the Workgroup for Electronic Data Exchange recommends that health-care providers create their own (more precise) crosswalks between ICD-9 and ICD-10. This is particularly important due to the fact that for at least

24 Radiology Business Journal | June/July 2011 | www.imagingbiz.com

one year after Medicare’s October 1, 2013, go-live date, providers will have to continue to process ICD-9 codes from prior to that date.

In addition, even though providers will be required to submit all payment claims in ICD-10 format, private payors are not required to make the transition, and a significant lag in the adoption of ICD-10 by some private payors is expected. “If providers aren’t careful, those differences could have major reimbursement consequences, including underpayments or overpayments of several times the correct amount, according to CMS,” Meyer writes.

ICD-10, however, captures a far greater level of detail than its predecessor.

With ICD-10-PCS procedure codes, for instance, one can differentiate body parts, surgical approaches, devices used, resource consumption, and outcomes.

Angioplasty has just one code in ICD-9, but 1,196 in ICD-10, enabling coders to specify the precise location of the blockage and the instruments used.

Note that transitioning to ICD-10 will require more than software upgrades; providers will be challenged to adapt clinical and business operations to meet the information demands of the new systems, primarily in the form of greater documentation of clinical detail. Because of the greater number of data fields required by ICD-10, providers must make the change to a new informationtransaction platform on January 1, 2012.

Crunch Time A big concern is whether organizations will be able to make the changes needed to adapt to the new code set, Meyer writes.

According to the American Hospital Association, half to two-thirds of hospitals had taken the necessary planning steps

by October 2010, and a December 2010 Health Information and Management Systems Society survey2 discovered that not even half of all providers, including health-care systems and physician practices, had a planning program in place for conversion to ICD-10.

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System, Newark, Delaware, were early in recognizing the potential of ICD-10 to enable them to make improvements in business and clinical operations, as well as to further the goals of health-care reform by making more targeted payments possible, Meyer writes. Because its IT resources were consumed by meeting meaningfuluse requirements and by the adoption of computerized provider order entry, the health system hired consulting help.

It also established a steering committee composed of physicians leaders and executives from nursing, finance, and IT in late 2010 to prepare for the change. The organization recently held a retreat to focus on ways to improve clinical documentation without gumming up workflow.

Another big concern is the financial impact of the change. Providers do not want to end up getting paid less than they are currently receiving for the same services, and insurers do not want to pay more than they are currently paying.

Insurers have started analyzing the most frequently used and highest-dollar codes; CMS insists that the transition be budget neutral and is mapping how ICD-9 codes translate to the more plentiful ICD-10 codes, resulting in some adjustments in code translations.

Failure to be prepared to submit all claims using ICD-10 codes by October 1, 2013, could result in serious disruptions in cash flow. In fact, some experts are suggesting that providers develop

financial contingency plans and work with banks to establish a working line of credit for up to three months. Given the fact that coders and billing personnel will initially experience productivity hits, this is not bad advice.

—Cheryl Proval References 1. Meyer H. Coding complexity: US health care gets ready for the coming of ICD-10.

Health Aff (Millwood). 2011;30:968-974.

2. Health Information and Management Systems Society.

HIMSS ICD10/5010 industry readiness survey. http://www.himss.org/content/files/ ProviderReadinessSurveyDecember2010. pdf. Accessed June 13, 2011.

numeric

RBMs in New Orleans: The Panel and the Pain

O

n June 7, 2011, at the Annual Summit of the RBMA in New Orleans, Louisiana, four CEOs and one senior leader— representing all five radiology benefit management (RBM) companies— participated in a panel discussion during a general session, “Face to Face With RBM CEOs: Shaping the Dialogue for Imaging’s New Realities.” Look for coverage of that session in the August/September issue of this magazine.

While the panelists provided insight into the current policies and future ambitions of the RBMs, a series of questions designed to probe audience experiences shed light on the administrative impact that these policies are having on the nation’s radiology practices.

1. Have RBMs had a noticeable negative effect on your volumes?

72%

Yes No

2. What year did you first notice the effect?

24%

2006

26%

2007

14%

2

17%

5

42%

18%

6. What additional administrative and operational costs have you incurred in the past fiscal year related to precertification management?

25%

0–$25,000 32%

21%

48%

None do

12%

3 4

5. Do RBMs permit you to obtain preauthorizations on behalf of your referring physicians?

Some do

3. How many RBMs do you deal with in your market?

1

50%

None

All do 10%

19%

2008

2010

41%

Some

28%

2009

4. How many of them have clearly communicated their criteria for imaging approval?

9% All

$25,001–$50,000

38%

More than $50,000

38%

18% 7. Is your practice considering adopting radiology decision-support software?

Yes No

26 Radiology Business Journal | June/July 2011 | www.imagingbiz.com

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COVER | The Bundling of Radiology

The Great CT Bundling Heist of 2011 With the new CPT codes for combined CT exams of the abdomen and pelvis, the bundling of radiology escalates, and experts advise radiology to prepare for further abasement of the imaging codes

By George Wiley

M

edicare is looking for misvalued imaging codes—and it has already found several for which it has reduced payment. Its efforts have dismayed radiologists. Facing more revenue losses from CMS and the private insurers that follow in the agency’s footprints, radiologists feel targeted and, as a specialty, misvalued themselves.

Gary Dee, MD, treasurer of Midstate Radiology Associates, Inc (Wallingford, Connecticut), says, “I understand that Medicare has no money, but the private insurance companies are taking money out of my pocket and putting it in their pockets.

It’s only going to their profit margins.”

Since the beginning of 2011, Medicare’s imposition of a new bundled CPT® code on a combined CT exam of the abdomen and pelvis has severely decreased imagingcenter revenues. Many radiologists (including Dee) are particularly upset that big insurance carriers are following Medicare’s lead by imposing the same cut on the combined procedure themselves, using the new single-payment code for a CT exam of the abdomen and pelvis for what was formerly reimbursed as a two-code exam of separate, though contiguous, body parts.

“I understand Medicare,” Dee says, “but I don’t think the private insurance carriers necessarily have the right to follow it. My health-care premiums are up 13%, and this change is taking 25% out of my practice, too. This is bleak.”

Midstate Radiology Associates is a 10physician practice in central Connecticut that operates seven imaging centers and reads for MidState Medical Center, a hospital in Wallingford. “A solo practice 28 Radiology Business Journal | June/July 2011 | www.imagingbiz.com

I understand Medicare, but I don’t think the private insurance carriers necessarily have the right to follow it.

My health-care premiums are up 13%, and this change is taking 25% out of my practice.

—Gary Dee, MD Midstate Radiology Associates, Inc

Any two CPT codes, in any specialty, that are submitted more than 75% of the time are now open to review. That will be for 2012, and there will be a lot of radiology codes that fall into that category.

—John A. Patti, MD, FACR Massachusetts General Hospital

of 10 people is not going to take on the Anthems and Aetnas,” Dee says. “The ACR® is doing the best that it can. We’re working longer and harder, but that’s not enough.”

John A. Patti, MD, FACR, a thoracicimaging specialist at Massachusetts General Hospital (MGH) in Boston, is chair of the ACR’s board of chancellors. He notes that the new bundled abdomen and pelvis code flows from a process that has been ongoing for years, but has recently been accelerated. Key to that acceleration have been reimbursement evaluations for CMS done by the RVS Update Committee (RUC) and a push by the Medicare Payment Advisory Commission (MedPAC) for more bundled codes.

“From our perspective,” Patti says, “this is really a process that has been going on at the RUC for quite a while.

It was generated by impetus from CMS, and particularly from MedPAC, for what they refer to as correct pricing. Initially, codes were reviewed every five years for misvaluation. That was very rigorous and defined, and did result in changes to many codes.”

Patti continues, “Then, CMS and MedPAC decided this review of misvalued codes needed to be stepped up; they also began looking at procedures that were paired more than 95% of the time. That

screening was then dropped to about 90%—and now we are embarking on a screening level of 75%. Any two CPT codes, in any specialty, that are submitted together more than 75% of the time are now open to review. That will be for 2012, and there will be a lot of radiology codes that fall into that category.”

The bottom line, as Patti traces it, is that radiologists should expect more imaging procedures that are frequently performed for a patient on the same day to be bundled under a single CPT code that reduces reimbursement, just as has happened with the newly bundled abdomen and pelvis code for CT exams.

“I don’t see this ending. The pressure is still on to look at these codes for bundling. If codes are submitted together more than 75% of the time, then the CPT Editorial Panel will have to look at those codes. The end point is money. I don’t think CMS will let up,” Patti says.

Greater Impact While the recent bundling of CT exams of the abdomen and pelvis might appear, at first glance, to be minimally detrimental financially, it has turned out to be anything but that. The dual exam is a common procedure. The exam can also be performed with contrast, without contrast, and before and after contrast, adding to the

financial impact and complexity when the codes are bundled and paid as one.

Just how much the bundling is costing radiology clinics and hospital-based practices is impossible to assess, since the bundling has only been in place since the start of the year. Dee says that his aggregate first-quarter returns for this year are down 25%, compared with 2010. He acknowledges that some of that decrease is probably due to reduced demand for advanced imaging generally, but a lot of it stems from the bundling of CT exams of the abdomen and pelvis by CMS—and the copycatting that has followed in the private sector, he maintains.

“We used to get more than $800 for a CT exam of the abdomen and pelvis with and without contrast; we’re down to around $400 now. That’s a huge drop,” he says.

He estimates that his practice does 1,000 combined abdomen and pelvis procedures per year that are bundled now.

He says, “That’s down $300 to $550 per exam. That’s $500,000. Where are we going to find that money? Our costs aren’t dropping. It’s a big number. The bundling of the abdomen and pelvis is the big one that tipped us over; with a big practice, this would be in the millions.”

Gregory M. Kusiak, MBA, is president of California Medical Business Services (CMBS), headquartered in Arcadia. CMBS is a wholly owned subsidiary of Hill Medical Corp, which provides radiology services to four imaging centers and a major Pasadena hospital. Hill employs 19 FTE radiologists and interprets about 350,000 exams yearly, Kusiak says. CMBS also operates a billing service that gives Kusiak a broader view of the impact of the new abdomen and pelvis code bundling.

Taken together across the Medicare and private-payor spectrum, Kusiak estimates, the new bundling of the various abdomen and pelvis CPT combinations, all by itself, is reducing hospital-based radiology revenue (mostly from an outpatient income stream) by a whopping 6%. “A hospital practice with reimbursements of $1 million a year could take a $60,000 hit from just this one change alone,” Kusiak says.

Of course, how much a practice is harmed by the abdomen and pelvis code bundling depends on how many such

www.imagingbiz.com | June/July 2011 | Radiology Business Journal 29

COVER | The Bundling of Radiology

at the Massachusetts General Physicians Organization (MGPO) in Boston and is chair of the RBMA payor-relations committee. What has jumped out at James about the newly bundled abdomen and pelvis exams is the reduced reimbursement level for the technical component.

“The applied RVUs for the bundled procedure are less than the RVUs for just the abdomen by itself,” James says.

According to a letter that the MGPO sent to CMS in 2010 (commenting on the proposed bundling for 2011), the technical-component reimbursement for the bundled code for a CT exam of the abdomen and pelvis, without contrast, comes in at 3.9 RVUs. The CT exam of the abdomen alone, without contrast, carries 4.3 RVUs. The old double-coded RVU for separate CT exams of the abdomen and pelvis carries 6.46 RVUs. The bundled codes for the procedures with contrast, and before and after contrast, are currently slightly higher in technical-component RVUs than the single exam is, but the new RVU amounts still represent a reduction from the old unbundled payments, according to the MGPO’s calculations

procedures the practice does. It also depends on how successful the practice or center is at negotiating reimbursement rates with private insurance companies.

As Patti notes, all payors must use the new bundled codes, but private insurance companies aren’t bound to pay Medicare reimbursement rates. They might pay more if they are contractually bound to do so, or if they find it advantageous to the broader relationship to do so.

“That becomes part of the negotiation,” Patti says. “Typically, the private payor uses RVUs. There’s very little horse trading going on, but there’s always the potential to have a negotiation. I’m not saying you should invoke negotiations because of bundling; however, if a radiology practice has the opportunity to negotiate a contract, it’s always best to do so.”

As Dee notes, for a small practice, the chance to win in negotiating with the big insurance companies amounts to no chance at all. Larger radiology practices can and do negotiate better-than-Medicare rates in the private-payor arena, however.

Technical Absurdities Christie James is group practice manager for radiology billing services

The MPGO’s letter to CMS states that the bundled technical-component RVUs do not “provide any recognition of the incremental work involved when performing these exams.” The letter asks CMS to rethink its RVU methodology for the bundled codes. The individual pelvic and abdominal CT exams both carry higher technical-component reimbursement, but James says that a radiology practice can’t just bill the dual exam as a single exam and collect the higher fee, either.

That could be considered fraudulent.

“Your report states abdomen and pelvis,” she says. The lower-paying bundled code must be used.

Pamela Kassing, MPA, RCC, the ACR’s senior economic advisor for economics and health policy, is the person principally charged with monitoring CMS bundling activity for the ACR. According to Kassing, both technical-component reimbursement and the radiologist’s professional fee have taken significant hits under the new abdomen and pelvis bundled codes (see table).

For the bundled abdominal and pelvic CT exams, Kassing says, technical reimbursement—which especially hits hospitals, since they own and operate

Table. ACR Comparison of RVUs and Payments for CT Exams of the Abdomen and Pelvis

Exam

2010 total RVUs

2011 total RVUs

2013 total RVUs

2011 (with conversion factor of $33.84)

2013 (with conversion 2011 factor of $33.84) HOPPS

72192 CT pelvis without contrast

PC (–26) TC

1.53 5.08

1.6 5.61

1.55 4.31

$54.15 $189.86

$52.46 $145.87

72193 CT pelvis with contrast

PC (–26) TC

1.63 6.31

1.71 7.02

1.66 5.47

$57.87 $237.58

$56.18 $185.13

72194 CT pelvis without contrast followed by with contrast

PC (–26) TC

1.71 8.41

1.79 9.39

1.75 7.38

$60.58 $317.79

$59.23 $249.77

74150 CT abdomen without contrast

PC (–26) TC

1.67 5.03

1.75 5.57

1.7 4.3

$59.23 $188.51

$57.53 $145.53

74160 CT abdomen with contrast

PC (–26) TC

1.78 7.17

1.87 8.03

1.82 6.39

$63.29 $271.77

$61.60 $216.26

74170 CT abdomen without contrast PC (–26) followed by with contrast TC

1.97 9.8

2.06 11.03

2.01 8.87

$69.72 $373.30

$68.03 $300.20

2010 composite rates

74176 CT abdomen/pelvis without contrast

PC (–26) TC

2.49 3.9

2.49 3.9

$84.27 $131.99

$84.27 $131.99

$193.85

$418.43

74177 CT abdomen/pelvis with contrast

PC (–26) TC

2.61 7.43

2.61 7.43

$88.33 $251.46

$88.33 $251.46

$299.81

$626.96

74178 CT abdomen/pelvis without PC (–26) contrast followed by with contrast TC

2.89 9.83

2.89 9.83

$97.81 $332.69

$97.81 $332.69

$334.24

$626.96

Abbreviations: HOPPS, Hospital Outpatient Prospective Payment System; PC, professional component; and TC, technical component

30 Radiology Business Journal | June/July 2011 | www.imagingbiz.com

Billing and Business Intelligence Technology: From Evolution to Revolution The narrow operating margins of today’s radiology business environment, underscored by ever-increasing pressure on reimbursement, mean practices need every advantage they can get. Once, x-ray films were developed by hand, just as billing and financial reporting was done by hand; though the digital revolution has rendered both of these methods obsolete, business intelligence technology for radiology has not kept pace with the rapid evolution of clinical technology—until now.

Smart practices know that billing, while cumbersome in and of itself, is only half of the revenue cycle management equation. Concealed within their financial data is the business intelligence they need to excel in a competitive marketplace, but accessing and interpreting this information has remained a burdensome process. In today’s environment, however, leveraging this data is no longer an option; it has become critical to practice survival.

For this reason, radiology professionals are increasingly seeking the same level of sophistication and technological evolution they have grown accustomed to in their clinical work on the business sides of their practices. Partnering advanced technology platforms with the expertise necessary to ensure that they are not leaving money on the table, practices are taking the traditional approach to billing and transforming it into true business intelligence.

Empowered with the metrics, benchmarks, modeling and forecasting long demanded by their peers in other industries, they are discovering a new path to success.

Evolved Billing Technology The complexity of the reimbursement process – including constantly changing coding and compliance requirements – makes billing a challenge for even the most robust radiology practice. Now more than ever, practices need confidence that they are capturing every charge, and that they are being appropriately reimbursed for all the work they do. Fortunately, there is now a system that can provide that certainty while furnishing practices with customized dashboards showing the health of the business at a glance.

The radiology industry is no stranger to paradigm shifts in clinical capability. Medical Billing & Management Services’ investment in its billing software brings the sophistication of today’s nextgeneration imaging technology to a world of revenue

cycle management that, for most practices, is still in the light-box era. A process that once required multiple FTE staff members is dramatically simplified, delivering the exceptional efficiency today’s practices need to survive.

This level of expertise in automation drives striking improvements in revenue. MBMS is a proven leader in financial performance metrics, leveraging sophisticated, proprietary billing technology to deliver 98% net collections, reduce bad debt to 4% and decrease days in accounts receivable by a third when compared with industry standards.

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The clinical revolution in radiology is well underway, but the business intelligence revolution is just beginning. With technology and tools that bring new sophistication to revenue cycle management, and the expertise necessary to correctly apply them, practices can make the right decisions they need to excel.

For more information: MBMS Radiology Billing 888.709.4580 info@mbms.net 203.610.9203 sales@mbms.net www.mbms.net

COVER | The Bundling of Radiology

The hospital is getting the big brunt of it, but we have substantial technical billings, too. We have definitely noticed a reimbursement impact, from both the technical and the professional sides.

—Christie James Massachusetts General Physicians Organization

We are looking at a lot of codes— some in interventional radiology and a lot in diagnostic radiology. [The ACR] still needs to get the word out that more bundling will be on the horizon.

—Pamela Kassing, MPA, RCC American College of Radiology

many CT systems—is half what the old reimbursement was for the procedures, when coded separately. In fact, she says, the bundled technical-fee reimbursement is, in some cases, 65% less than the old technical-fee payments for separately coded exams.

Professional Fees On the professional-reimbursement side, Kassing says, the RUC imposed a 50% reduction in physician work for CT exams of the abdomen and pelvis exams done together, even though the ACR’s survey data showed that the full physician-work value for two separate exams was accurate in reflecting the work of the combined exams; there were no economies gained by performing the exams together. The end result, Kassing says, is that radiologists are now being paid 25% less to interpret bundled CT exams of the abdomen and pelvis than they were being paid to interpret the exams of both body areas in the past.

Is this reduced professional reimbursement justified? Dee doesn’t think so. “On the technical side, the patient is only on the table once, but on the professional side, I argue that it takes longer to read. I’ve got to coordinate the two. The whole thing doesn’t make sense. It’s unfair,” Dee says.

Kassing agrees with others that the financial impact of the bundling has been severe. “It could be as much as $4 million

in annual revenue for each imaging center,” she says. Some losses, she adds, “are as low as $250,000, but some are much higher, depending on the volume and the case mix. That’s a huge impact, when they really didn’t see it coming.”

Hospitals Feel the Pain To date, freestanding outpatient imaging centers paid under the Medicare Physician Fee Schedule (MPFS) have borne the brunt of payment reductions aimed at imaging providers. This time around, hospitals are getting a taste of the same medicine.

The MPFS codes are based on RVUs, which are calculated differently than Hospital Outpatient Prospective Payment System (HOPPS) relative weights are calculated, Kassing explains. In 2010, when CT exams of the abdomen and pelvis were done in hospital outpatient settings, the hospitals were paid about twice as much as they will be paid this year for the bundled exam.

“The hospitals are quite upset about this,” Kassing says. “We did meet with Medicare to explain to them that they made errors with pricing the new codes and are waiting for this year’s proposed rule to see if CMS will correct it.”

Under HOPPS, services are assigned to Ambulatory Payment Classifications (APCs). There are APC codes for single CT studies, as well as composite APCs,

32 Radiology Business Journal | June/July 2011 | www.imagingbiz.com

which are paid at a higher rate. Silva1 notes in a recent report in the Journal of the American College of Radiology: JACR: “CMS assigned the new bundled codes to the APCs for single CT studies, failing to acknowledge that the new codes actually represent more than one service.”

The technical-fee reductions in the bundled codes have had the most impact, according to James (who is responsible for the professional-revenue cycle for MGPO Radiology Associates), even though both technical and professional fees have been reduced. The technicalfee reimbursements for the bundled procedures have ultimately fallen by more than 50%, she says.

“The hospital is getting the big brunt of it, but we have substantial technical billings, too. We have definitely noticed a reimbursement impact, from both the technical and the professional sides,” James says. One reason that professional reimbursements for the bundled abdomen and pelvis billings haven’t fallen more is that some private insurers and radiology benefit management companies have agreed that radiologists do, indeed, have more work to do to interpret a bundled exam, James says.

These payors have very recently raised the reimbursements for the professional fees—sometimes, back to 100% of the fees for the unbundled exams—although the gross reimbursement from all payors remains around 60% on the professional side, compared with the old unbundled payments, James says. She adds that for several months before they backpedaled, the private payors were participating in the payment reductions by using the new Medicare reimbursement rates for the bundled codes.

“They got a ton of money from those professional fees off bundling. That was a win for everybody on the insurer and payor side,” James says. “They’ve started to back off; they’ve reversed, but they had done the reduced payment for half a year.”

More Bundling on the Way Kassing says that the same-day abdomen and pelvis exam isn’t the first code to carry a reduced CMS reimbursement from bundling—and it won’t be the last.

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COVER | The Bundling of Radiology

that began about four years ago, Kassing says, CMS bundled myocardial-perfusion imaging. She recalls, “It was quite a significant hit for nuclear medicine, although it didn’t get noticed as much as the CT of the abdomen and pelvis.”

Kassing says that lower-extremity revascularization imaging—which has the first codes to be picked up by CMS screening for companion procedures at the 75% level of combined performance—is on its way to being bundled. Beyond that, she says, CT angiography of the abdomen and pelvis is set to be bundled, too.

“That’s going to be big news, but that’s 2012,” Kassing says.

At the 75% screening level, Kassing says, “We are looking at a lot of codes—some in interventional radiology and a lot in diagnostic radiology.” The ACR “still needs to get the word out that more bundling will be on the horizon,” Kassing says.

Multiple-procedure Discounts Supposedly misvalued codes that can be bundled aren’t the only target of CMS. Reduced Medicare reimbursements have already been implemented for a host of procedures done for a patient on the same day. These reductions are taking place through a multiple-procedure

discounting process.

James says that much of the multipleprocedure discounting occurs in the care of cancer patients. So far, only technical fees have been hit; she says, “All same-day multiple procedures are being reduced 50%.” She says that professional fees for multiple procedures have not been reduced, although MedPAC has recommended that they, too, should be cut in 2012. “The ACR is lobbying against this,” she adds.

Multiple-procedure discounting adds up to serious money. A memo from a consultant, which the ACR shared with the RBMA, estimates the overall impact of the multiprocedure discount at $193 million in 2011, $161 million in 2012, and $149 million in 2013.

In addition to instituting all this bundling and discounting of imaging reimbursement, the DHHS secretary is operating under a health-reform mandate to look for so-called misvalued codes and outsized reimbursements paid to physicians. Kusiak says that the congressional mandate to the DHHS under the Patient Protection and Affordable Care Act effectively gives the secretary the ability to impose cuts in reimbursement unilaterally for services designated as misvalued.

“The DHHS secretary can be overruled, but it pretty much takes an act of Congress to do it,” Kusiak says.

“People think radiology is a bottomless pit of money that can be used to cover other people’s sins.” Kassing says that the criteria that the DHHS secretary can use to screen for misvaluation include fastgrowing services, those reflecting changes in practice expenses, those that are billed multiple times, those involving new technology, or those meeting any other criterion determined appropriate. It is likely that imaging codes will be subject to DHHS review, Kassing says.

Fighting, but Losing One reason that the bundled abdomen and pelvis reimbursements were so shocking to radiologists this year, Kassing says, is that they occurred largely without warning. By virtue of a confidentiality agreement with the medical panel that produces each new round of codes, the ACR can’t release the new figures until they’ve officially been made public. The ACR can comment privately, however, and it can lobby CMS not to impose the new codes.

Through these activities, the ACR was able to delay the issuance of bundled

The 2012 Hit List: Code Pairs That Meet the 75% Threshold

R

adiology first felt the effects of the bundling initiative launched by CMS in 2010, with the creation of combined CPT® codes for myocardial perfusion, wall motion, and ejection fraction (78451–78454); arteriovenous shunt dialysis-catheter procedures, along with radiological supervision and interpretation (36147 and 36148); and facet-joint injection procedures that include imaging guidance (64490–64495).

For 2011, CMS escalated the activity with three new targets, including the newly bundled codes for CT exams of the abdomen and pelvis (74176, 74177, and 74178); lower-extremity revascularization codes that include accessing and catheterizing the vessel traversing the lesion, radiological supervision and interpretation, embolic protection, closure of the arteriotomy (by any method), imaging performed to document completion of the intervention (as well as the interventions performed), and moderate conscious sedation (37220–37235); and atherectomy above the inguinal ligaments,

including radiological supervision and interpretation (0234T–0238T).

An ACR communication1 reminds radiologists that this initiative is affecting all of medicine, that the ACR is compelled to participate in the process, and that it is constrained from reporting on the deliberations. “While the ACR is not permitted to provide detailed information on the codes and descriptors developed for 2012 at this time, we can inform our members of codes being considered for bundling,” the communication says.

It also notes that in response to provider requests, the AMA will issue the 2012 version of the CPT codes on August 31, 2011, although the values assigned to the codes by CMS will not be available until the publication of the 2012 Medicare Physician Fee Schedule in November. The ACR communication lists five code pairs that have been identified as being performed together more than 75% of the time—and that are, therefore, under consideration for bundling in 2012:

34 Radiology Business Journal | June/July 2011 | www.imagingbiz.com

• CT angiography of the abdomen and pelvis (74175 and 72191); • renal angiography with radiological supervision and interpretation (36245– 35248, 75722, and 75724); • inferior vena cava filter placement and retrieval with radiological supervision and interpretation (37620 and 75940); • abdominal paracentesis with imaging guidance (49080, 49081, 76942, and 77012); and • sacroiliac-joint injections with radiological supervision and interpretation (27096 and 73542).

—Cheryl Proval Reference 1. ACR. Bundling of CPT codes to continue in 2012. http://www.acr.org/Hidden/ Economics/FeaturedCategories/Pubs/ coding_source/archives/MarApr2011/ Bundling-of-CPT-Codes-to-Continue-in2012.aspx. Accessed June 15, 2011.

RIS/PACS

RBJ_Bulletin_RIS-PACS_6-2011.indd 1

6/15/11 10:26 AM

COVER | The Bundling of Radiology

One result of this is you could see more conservative use of contrast media and more conservative selection of body regions for imaging. Some of these procedures are radiologist elective. The radiologist will determine what’s necessary to make the diagnosis.

—Gregory M. Kusiak, MBA California Medical Business Services

codes for several years, Kassing says—but then, as pressure built to reduce healthcare spending, the writing on the wall became clear. “If we didn’t participate, it was going to happen anyway,” Kassing says, “so we participated.”

The ACR did its own studies, and when the abdomen and pelvis bundling was proposed, it lobbied CMS to leave the old reimbursements in place. Its efforts, though, largely fell on deaf ears.

In January 2011, Bibb Allen Jr, MD, FACR, chair of the ACR’s commission on economics, wrote a stinging memo to ACR members, noting that CMS “did not accept ACR’s recommendations” to maintain separate coding and valuation for the abdominal and pelvic CT exams.

He charges that the CMS designation of the services as misvalued was, in fact, a euphemism for what the agency really thought: that the radiology services were overvalued. In other words, radiologists weren’t worth what they were being paid.

What CMS was doing was transferring reimbursements from radiologists to primary-care physicians, according to Allen.

Such reimbursement changes are part of a larger effort being conducted by CMS, Congress, MedPAC, the Government Accountability Office, the OIG, “and other policy makers in Washington to find savings in the Medicare program and redistribute dollars to primary-care providers,” Allen writes.

Paul S. Viviano is board chair and CEO of Alliance HealthCare Services, Newport Beach, California. Through a subsidiary, Alliance HealthCare Services provides imaging services to hospitals

and imaging centers. It is a large company that performs more than a million exams annually.

Viviano says that his biggest concern about the abdomen and pelvis bundling introduced by CMS is that it will set a precedent for the agency to change the MPFS without providers getting the chance to comment. “Without posting for comment, CMS unilaterally changed the structure of the MPFS,” Viviano says.

“From a policy perspective, this is very dangerous.”

Viviano says that lobbying needs to continue to make sure that in the future, CMS issues proposed reimbursement changes for comment, so that studies can be done on their impact prior to implementation. “Our eyes are open that imaging has been a target for cuts, and we are worried that will continue to be the case,” Viviano says.

There are a number of organizations lobbying on behalf of radiologists (in addition to the ACR). One of the largest is the RBMA. Michael R. Mabry is the RBMA’s executive director, and he says that one argument that the RBMA is making, as it continues to fight discounted reimbursements, is that bundling codes does not make sense clinically.

There are clinical reasons to perform abdominal and pelvic exams together, and these reasons should not be overlooked in reimbursing for the procedures, Mabry says. Clinical demands should be highlighted when there is discussion of future bundling by CMS. “We are working to come up with a strategy for dealing with these changes,” Mabry says. “We are raising issues and

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making CMS aware of them. We are trying to make them see that there is an impact on patient access, on imaging centers staying open, and on how radiology is provided.”

It’s too early to say how the abdomen and pelvis bundling has affected the provision of imaging services nationally, if it has, Mabry adds. Those imaging centers that rely on CT exams might be hurt most.

“The continuing reimbursement squeeze is making radiology groups take a harder look at their other costs and find opportunities to shed or defer expenses,” he says.

Surviving on Less Kusiak says that, in his view, the bundling of the abdomen and pelvis codes might cause imaging providers to become more conservative in performing the lower-paying bundled exams. “One result of this is you could see more conservative use of contrast media and more conservative selection of body regions for imaging,” he says. “Some of these procedures are radiologist elective.

The radiologist will determine what’s necessary to make the diagnosis.”

There might be more single abdominal CT exams or pelvic CT exams performed instead of poorly paid combination studies, Kusiak says. “I think this will encourage people to be much more conservative,” he says. “The radiologist may not go that extra mile, since in essence, he or she is negatively rewarded.”

The bundling of services with lower reimbursements attached is just one more step in a series of payment reductions that have left imaging centers across the country available at fire-sale prices, Kusiak says. It isn’t just radiologists who are being hurt, either. The advanced systems available from closed imaging centers are piling up on the market, he says, and the incomes of equipment manufacturers have plummeted.

George Wiley is a contributing writer for Radiology Business Journal.

Reference 1. Silva E. CT abdomen and pelvis: a case study in devaluation. J Am Coll Radiol.

2011;8(5):300-301.

The Top Five Medical Imaging IT Projects of 2010

The winning entries in the 2010 competition are presented here

W

hen Radiology Business Journal was founded four years ago, it was with the understanding that IT represented not just the platform for image interpretation, exchange, and archiving, but also a broad foundation for practice operations, communications, and financial analysis. Earlier this year (and with that in mind), we approached the Society for Imaging Informatics in Medicine (SIIM) to collaborate on a competition to recognize the remarkable innovation we were witnessing in medical imaging, across practice settings and practice domains.

We believed that the combined resources of our two organizations would generate more interest and offer greater results legitimacy for a competition to identify the Top Five Medical Imaging IT Projects of 2010.

Our sincere thanks go to Anna Marie Mason, SIIMâ&#x20AC;&#x2122;s executive director; to the SIIM board, for approving the idea and agreeing to judge and publicize the contest to SIIM members; and (last, but not least), our panel of six judges (see page 43).

We received 28 entries in the categories of clinical, interoperability, communications, business-intelligence, and security projects: All of them were

very interesting, many were excellent, and five of them received the highest marks from the judges. The criteria were innovation/ingenuity; meeting a critical, urgent, or unmet need; improving quality; validating/evaluating a tool; and having the potential to be generalized to other institutions.

Here are the winning entries (edited for length and style), along with some insight into the work of the innovators who submitted them. We thank all of you who took the time to enter and invite all imaging informaticists to look for our second annual contest early in 2012. â&#x20AC;&#x201D;Cheryl Proval, Editor

Hospitals Achieve Success by Adopting the Right Technology McKesson customers weigh in on the issues

How has integrating the right technologies improved the standard of care?

In healthcare, time is of the essence. The radiology report is vital to the decisions leading to the patient’s treatment. At Main Line Health in suburban Philadelphia, the organization has implemented integrated systems that deliver a signed radiology report directly to the attending physician in minutes.

Radiologists sign off more than 85% of all reports immediately at the time they are dictated, when they are fresh in their minds. The integrated PACS and voice dictation system is so easy-to-use that radiologists self-edit 90% of cases. “The system is surprisingly easy to use, technically stable and truly facilitates patient care,” states Harry Zegel, M.D., chairman of radiology for Main Line Health.

“Since implementing, we have had numerous new radiologists that have joined our group.

Overwhelmingly, these radiologists have indicated our system is vastly superior to similar systems they were using at other hospitals.”

How has healthcare IT increased reporting volume while improving report turnaround time for accelerated decision making?

When Parkland Health & Hospital System, a 990-bed county hospital for Dallas and one of four teaching hospitals for the University of Texas (UT), began plans to construct a new facility, the administration decided it was time to rebuild from the inside out.

At the time, the Dallas county hospital had five different PACS in place and a particularly outdated one in the radiology department. Recently, Parkland began implementing an enterprise PACS for a consolidated, open imaging platform that integrates with Parkland’s third-party electronic medical record (EMR), third-party viewing applications, and various teaching and conferencing applications. “As an academic institution, we have a diverse workflow that encompasses multiple patient care provider levels,” says Maviea Easter, manager of Diagnostic Imaging and Informatics at Parkland. “Our enterprise PACS has a flexible workflow, with highly ranked disaster recovery and a neutral platform that allows us to integrate with third parties and to easily add imaging to other ‘ologies in the future.”

How did updating your PACS technology help you meet the growing needs of your healthcare organization?

IASIS Healthcare Corporation in Franklin, Tenn., found that interoperability became an issue with the previous PACS product, tells Mark Watts, corporate director of enterprise imaging with operations and IT leadership. It just never kept pace with the changes in healthcare, and it was no longer able to grow with the changing demands of the organization. By replacing it with the right technology, which included the transfer of 3.2 million studies to a new archive — without a second of down time, IASIS quickly realized the benefits that a new-generation PACS brought to its ability to deliver service and better patient care.

How has technology, and the right partner, strengthened your commitment to quality care in your patient community?

With a new PACS, cardiology PACS (CPACS) and voice recognition system implemented early in 2010, Davis Health System in northern West Virginia knew it was positioned for the changing face of healthcare.

Although it is a small 90-bed community hospital, Davis Health System has a busy radiology department — doing more than 75,000 imaging studies per year.

The health system knew it needed to partner with a technology vendor that would give it the same type of focus as a larger university hospital. “There were several instances that could have derailed the implementation project or pushed it behind schedule were it not for our vendor’s service and dedication,” says Nina Virone, CIO of Davis Health System. “If there was a roadblock, they removed it.”

For more stories like this, go to www.AllAboutPACS.com Copyright © 2011 McKesson Corporation and/or one of its subsidiaries. All rights reserved.

The Top Five Medical Imaging IT Projects of 2010

Yun (Rob) Sheu, MD, is a radiology resident at the University of Pittsburgh Medical Center in Pennsylvania.

Peer-review System With Brains Peer review is often looked upon as inefficient and without objective results by many radiologists, despite its educational value and improvement of patient care, Sheu notes in his winning entry. He was convinced, however, that there was a better way. “Applying a mathematical cost model to guide the selection of radiology exams for peer review is feasible,” he says.

Barton Branstetter, MD, was the principal investigator, and three mathematicians collaborated with the radiologists: Elie Feder, PhD; Igor Balsim, PhD; and Victor Levin, PhD. While peer review is an essential component of radiologists’ practice, the increasing constraints on a radiologist’s time require this process to be as efficient and effective as possible. “Our eventual goal is to streamline the process more and build the model into one of the new electronic peer-review systems, ACR® RADPEER™ being an example,” Sheu continues. “To our knowledge, this has not been done. Currently, the informatics department at our institution is working on an in-house peer-review system that is incorporated in the PACS, and we hope, eventually, to use our model in the system.”

Winning Entry 1 Problem: Although advances have been made in incorporating peer review into the daily workflow, cases to be reviewed are still selected at random, without consideration of prior errors or the consequences of those errors.

Solution: Starting in 2009, and using data collected over a period of several years, we created a computer model that calculated the cost for 12 categories that can be used to target areas of weakness; cost is defined as the liability addressed per unit of peerreview time. Given a unit of peer-review time, the cost function represents the expected cost (both financial and medical) to the hospital and patient, if the error is not fixed.

Four attributes of past errors were

used to calculate cost: morbidity, financial expenditures, probability of occurrence (based on past data), and the time needed for peer review of the study in question.

Our model determined the modality and body part for each radiologist who had, based on past errors, the greatest potential for future liability. This information would then allow a peer-review committee to pick review cases selectively for a given radiologist to achieve a more efficient review, maximizing the statistical likelihood of discovering a true area of weakness.

A large sample of more than 64,000 significant discordances—based on overnight preliminary reports—over a fiveyear period was compiled. Discordances were adjudicated by specialty-trained radiologists. The preliminary and final diagnoses were categorized into approximately 20 broad categories per body part. Each error type consisted of an ordered pair of diagnoses for which the preliminary diagnosis and final diagnosis were different. Each of these error types was then assigned a numerical financialcost value and a morbidity-cost value based on standardized scoring criteria.

The computer model calculated the total cost as morbidity cost times financial cost times probability of error, with that product then divided by time needed for peer review of the study. The total cost was compiled for 246 on-call attending radiologists and residents in each of 12 categories spanning three modalities (CR, CT, and MRI) and four body systems (neurological, abdominal, thoracic, and musculoskeletal).

The category with the highest cost was then selected as the one that should be preferentially examined in future peer reviews. The total number of cases read for each category was also determined for each attending radiologist and resident.

The universal probability of an error for each category was compiled using data from all radiologists, and the total cost was calculated. Last, the average cost per category and the range of costs per category were tabulated.

Technology: The model supplies the morbidity and mortality costs of errors committed during overnight calls. It then tabulates the total error cost for a particular radiologist and for the

radiology department as a whole. The program is easily modifiable, constantly updates the cost functions as new data are received, and suggests the best test to review (whenever an opportunity for review arises).

Results: “Applying a mathematical cost model to guide the selection of radiology exams for peer review is feasible,” Sheu says. In addition, he notes, the study creates a baseline evaluation, for each of the participating attending radiologists, against which future errors can be compared. The advantages of the model are that it is flexible, with easy adjustment of scoring values, and that additional gradations can be added as new data become available.

Clinically, such information is useful in many ways. It is useful to radiologists and residents because it directs the focus of future study, and it is useful to radiology departments because it allows the administration to monitor the performance of all staff members, relative to their peers. Global mistakes can be detected and communicated to staff members to allow more care to be taken with high-risk studies.

These data also provide a quantifiable way to ensure improvement in weak areas. For a residency-program director, the model can detect global deficiencies among the residents that can be remedied using targeted teaching. Cases for daily case conferences can be selected from the category with the greatest average cost.

From residents’ standpoint, RADPEER provides information on what mistakes they are making, what impact the mistakes had, how many other people in their peer group made the same mistakes, and what to work on in the future. With targeted case selection, we hope to reduce the number of cases needed for a successful peer review, saving radiologists’ time and providing concrete evidence that peer review is having a positive effect.

Conclusion: By identifying trends in errors, as well as their costs for patients and hospitals, this proposed model of peer-review case selection will allow a more relevant selection of future cases for review, in addition to providing statistically accurate ways of monitoring physician improvement and resolving areas of weakness.

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The Top Five Medical Imaging IT Projects of 2010

Alberto Goldszal, PhD, is CIO of University Radiology Group, PC, in New Brunswick, New Jersey.

Interoperability: PACS Experanza Beginning in 2008, Goldszal’s goal was to create one enriched reading environment for a practice that reads a million studies annually from five distinct hospital systems, 10 outpatient imaging office locations, and three teleradiology clients, aggregating studies from all sites for the purpose of accessing prior studies.

University Radiology Group went live with the solution in 2008, starting with one site. Other sites are being gradually phased in at intervals of approximately three months. “It’s definitely doing what it was designed to do,” Goldszal says. “It’s an organic project, however, and it keeps on growing and changing.”

Currently, the practice is fully engaged in developing a regional imaging exchange in Central New Jersey. There, imaging studies originating from multiple unaffiliated organizations will be logically grouped by patient and presented at the point of care whenever required.

Winning Entry 2 Problem: University Radiology Group wanted to provide fast, efficient, accurate subspecialty interpretations based on the most complete clinical information available.

Solution: We developed a crossinstitutional, patient-centered, longitudinal imaging database that delivers patients’ entire imaging history (regardless of image-acquisition site) and uses a standard viewing platform.

The PACS aggregates clinical results and longitudinal imaging studies across healthcare organizations, using networking technology, as well as aggregated DICOM-based datasets; aggregated HL7based RIS datasets; and a combination of DICOM, RIS, and nonstandard data, such as scanned documents. The system combines patient datasets stored in multiple unaffiliated sites under different medical-record numbers.

Technology: At the heart of the crossinstitutional PACS is a dynamic electronic master patient index—an algorithm

that performs probabilistic matching of patient data scattered across health-care institutions, in the absence of a common and unique health-care identifier. The solution is implemented using offthe-shelf components, in addition to a commercial PACS, reporting system, and interface engine. No customization was necessary.

Results: We have developed and implemented a longitudinal, patientcentered imaging database of radiological studies acquired at multiple, unaffiliated health-care organizations. A live system aggregates and provides the final interpretation for more than a million studies that originate from 18 locations and from nine distinct, unaffiliated PACS/ RIS implementations.

Cases are presented to geographically distributed interpreting radiologists, who access all studies, via global worklists, through a standard diagnostic workstation.

Aggregated patient data presented to each radiologist include historical exams with final reports, ancillary clinical data (such as technologist and nursing notes), and patient demographic data originating from multiple data sources.

Upon interpretation, final results are automatically transmitted to the native RIS and/or electronic medical record (EMR) system for the permanent record, and to clinical departments (such as the emergency department) for immediate patient-care decisions. The consolidation of patient records is possible due to the development and implementation of HL7-based orders/results interfaces or HL7-based registration and admission, discharge, and transfer (ADT) interfaces between University Radiology Group’s system and the RIS (or equivalent orderentry system) of the image-acquisition site.

Based on the patient demographic information (including name, date of birth, gender, Social Security number, and address) available in the order or registration stream drawn from the RIS at each facility, we are able automatically to perform a DICOM Query/Retrieve or DICOM C-Move to fetch the corresponding new and old imaging studies stored in the corresponding hospital’s PACS. In case an HL7-based ADT or electronic order is not available, our

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system is capable of abstracting enough demographic information from the DICOM header (available in the imaging study) to trigger the fetching of prior images and historical medical records.

The system—using the probabilistic matching algorithm—continually links the patient’s identity across all health-care facilities with which we connect, allowing all-encompassing access to relevant prior images and clinical information stored across regional health-care organizations.

Conclusion: Our solution represents a major departure from traditional methods that rely on a single PACS and an institutional medical-record number to store and manage patient data. These schemata only provide access to a limited set of imaging and clinical history. We believe the lack of complete patient history can lead to duplicative (and often, unnecessary) exams, lower-quality diagnoses, and/or delayed results. Our solution accounts for these shortcomings and promotes better multisite data integration.

Li Lillian Hou, MS, CIIP, is a specialist programmer, radiology information services, at the University of Chicago Medical Center in illinois.

Liberating CT Workflow Postacquisition workflow is a major bottleneck in busy hospital CT suites, and the University of Chicago Medical Center (UCMC) was no exception. “While it takes only seconds to scan a patient, it requires many minutes to generate the reconstruction and advanced visualization series on the scanner,” according to Hou, who collaborated with her PACS and CT modality vendor to develop an automated workflow that offloaded postprocessing—freeing the scanner to scan—and eliminated paper.

Phase one of this project, called closed-loop imaging (CLI), began in February 2008. Phase two was launched in April 2009 and went live in April 2010. Deeming the project complete, given that it underwent three months of clinical trials, Hou currently is working on the hospital’s EMR system businessintelligence team to support meaningful use and other analytics projects.

Winning Entry 3 Problem: A major bottleneck in UCMC’s CT imaging workflow is CT postacquisition workflow. In addition, existing workflow requires technologists to push the study to its destinations, fill in paper forms and scan them into the PACS, and manually set up the presentation state in the PACS. The paper-based information that is scanned into the PACS as a secondary image cannot be easily leveraged for subsequent business intelligence or analytics.

Solution: The UCMC imaging-informatics team and the CT and PACS vendor jointly developed an optimized postacquisition workflow model that offloads from the scanner all advanced visualization series to an image-processing and -routing service, thus allowing the CT scanner to perform only scanning, imaging quality assurance, thin-slice reconstruction, and autosending of the thin-slice series to the image-processing and -routing service.

Once that service receives the study, it asks an intelligent imaging protocol service to get the rules that apply to the study, including protocols for advanced visualization series, routing destination, and notification requirements. This completely frees the CT scanner for the next patient, once all actual scanning is complete, and it significantly improves the efficiency of CT-scanner utilization.

The solution makes PACS autohanging-protocol rules easier to define, and automated presentation states can now be created by metadata supplied by the image-processing and -routing service, thus significantly minimizing manual intervention by technologists.

To address the manual scanning of paperwork, a document-scanning service was developed: Documents are scanned into the system at the point of the reception by clerical staff, rather than by a technologist. A technologist portal service was developed to preload patient/exam information, prevent repeated manual data entries, reduce errors, and save time for technologists.

Technology: The radiology order service, document-scanning service, intelligent imaging protocol service, imageprocessing and -routing service, and technologist portal service were built for optimizing the postacquisition workflow, based on service-oriented architecture.

The radiology order service provides radiology orders from the hospital information system (HIS) or RIS to the other services, based on such query criteria as order status, appointment time, modality, specialty, and anatomic region.

The document-scanning service is a tool for scanning paper forms, such as those for external laboratory results and contrast screenings. The intelligent imaging protocol service is a rules engine that provides clinical decisions on imaging protocols, as well as workflow rules based on clinical needs.

The image-processing and -routing service processes imaging protocols and workflow rules based on the query results from the intelligent imaging protocol service; the technologist portal service provides a Web tool for technologists, replacing paperwork. An application service provider, SQL server, DICOM library, and other technologies were used to create the solution.

Results: A clinical trial using abdomen protocols was conducted from April 20 through July 20, 2010. Six attending radiologists, eight residents, 13 technologists, and front-desk coordinators participated the trial. In the control (nonCLI) cases, the radiologist, technologist, and front-desk coordinator used normal workflow, in which paper forms— including requisitions, contrast-screening forms, protocol forms, charge forms, and technologists’ logs—were carried and operated from during each step of the imaging process. Technologists waited for the CT scanner to finish the advanced visualization series, pushed the series to the PACS, waited for all images to arrive in the PACS, and manually completed presentation setup and scanning of all paper forms into the PACS. In the experimental (CLI) cases, appointment staff used the documentscanning service to scan the paper forms. Technologists used the online technologist portal, and the manual steps after scanning were automated.

During the trial, all abdominal outpatient appointments scheduled between 8:30 am and 4 pm on Tuesdays and Thursdays were handled using CLI workflow, while other appointments were handled using non-CLI workflow to generate a random population of measurement

data. An image-quality tool was used by the radiologist for both CLI and non-CLI cases to evaluate accuracy and quality.

One CT scanner was used for CLI cases; the other six, for non-CLI cases.

The trial demonstrated multiple improvements. Paper was eliminated, and the workflow was streamlined by having paper forms online and access-ible, instead of having technologists manually scan the paper forms into the PACS. This also eliminated unnecessary waste of PACS storage, since the scanned paper was stored in the PACS as a secondary captured-image series.

In addition, autoextraction of laboratory results and preloading of patient/exam information provided the information needed by radiologists for protocols, using a single portal to improve accuracy and efficiency.

The online protocol worklist is available at any time and anywhere, eliminating manual processes and physical/time restraints, and auto-ontology mapping from radiologist protocols to CT machinery protocols eliminates manual translation, avoids errors, and saves both CT-scanner and technologist time.

The trial also demonstrated that offloading advanced visualization from the CT scanner saves additional CTscanner and technologist time. The presentation state was set automatically in PACS, also saving technologist time, and image quality was improved, with respect to missing series in PACS, because the protocol is automated.

Additional data, collected using both stopwatch time/motion and system timestamps, corroborate these improvements. All abdominal protocols were divided into two categories: a routine protocol, consisting of one scout and one or two scanning phases (for example, with or without contrast), and a complex protocol, consisting of one scout and more than two scanning phases (such as angiography protocols, which typically comprise one phase without contrast, one arterial and one venous phase with contrast, and one delay phase).

For the routine abdominal protocols, CT-scanner efficiency mean time (from the start scan scout command to the availability of the scanner for the next patient) improved by 78.06%, from

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The Top Five Medical Imaging IT Projects of 2010

14 minutes 17 seconds to 3 minutes 8 seconds. For the complex abdomen protocols, mean time improved by 61.17%, from 27 minutes 54 seconds to 10 minutes 50 seconds.

Conclusion: Using integration based on service-oriented architecture, including the image modality, can effectively integrate heterogeneous medical devices and information systems to improve workflow. The use of openplatform software architecture should be encouraged for advanced modalities to empower users to maximize workflow efficiency.

Michael P. Recht, MD, PhD, is chair of the department of radiology at NYU Langone Medical Center in New York, New York.

Pumping Up Productivity In May 2009, Recht and his colleagues decided that departmental workflow, communications, and productivity needed to be kicked up a notch. The key to attaining this objective, they concluded, was to build a customizable, flexible, easily updatable application that would reside atop the PACS, RIS, and other information systems and integrate

a variety of functions—from electronic protocols to data mining and much more.

The project, which kicked off in May 2009 with a request for proposals and went live in October and November 2010, was a highly collaborative effort by members of NYU Langone Medical Center’s department of radiology (radiologists, technologists, administrators, and radiology IT personnel) and its IT department.

“The initial stages have been completed and have had a major impact,” Recht says.

“Our current work is centered on using our new systems to mine our data to manage our department more efficiently.

For example, over the past year, we have developed a strategy map and balanced scorecard for our department. We also are working with our new system to provide data related to our key performance indicators, as well as to understand deviations from our benchmarks.” Other related initiatives underway include using the system to mine data for research— such as radiation-dose, utilizationmanagement, and outcome-analysis studies.

“The changing economic climate has made active management of a radiology department imperative,” Recht says.

“Such active management requires the availability of real-time data. The analytic module integrated into our system gives our leadership team the ability to access such information in a flexible, userfriendly way.”

Winning Entry 4 Problem: Previous PACS and RIS implementations lacked the workflow, communications, and analytics applications needed to execute exam protocols, rapid and accurate image interpretation, data mining for research and operational efficiency, access to online journals, and other critical daily tasks effectively.

Solution: We first identified the categories of systems needed, including PACS, integrated viewers for nuclear medicine

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and ultrasound, a vendor-neutral archive, voice-recognition systems, advanced visualization, and document management.

We used our existing RIS. We then identified an applications specialist vendor to create a customized, tightly integrated (but loosely coupled) software application called PRISM, layered on top of these systems.

This layer offers extensive functionality, including customizable reading worklists, electronic protocols, radiology and technologist synchronous and asynchronous communications, qualitycontrol systems, residents’ workflow, search and research tools, teaching files, document management, real-time metrics, and (soon) radiation-dose tracking. This layer is now the front end interface used by all members of our department.

Technology: PRISM was built atop industry-standard Web-server databases, computer languages, and communication protocols. A variety of application programming interfaces and messaging systems were used to communicate with, control, and respond to underlying components in the PACS, RIS, and other systems. A thin-client configuration with an automatic updating infrastructure was used to allow growth and change over time. Reliability was ensured though the use of high-availability systems with redundant servers.

Results: Electronic protocols and reliable synchronous and asynchronous electronic communication (instant messaging, integrated email, and technology notes that open automatically with the launching of each exam) between technologists and radiologists allow for more accurate exam protocols and monitoring. Technologists have become a more integral component of the clinical care team, increasing their morale.

Integrating the application portal with the EMR allows the EMR to be opened in context when each exam’s protocol is set and/or the exam is launched. This gives us more informed and optimal protocols, the convenient (and rapid) ability to check laboratory values, and better access to clinical concerns during image interpretation. An embedded documentmanagement system allows for easy and reliable integration of outside reports and other relevant documents. Electronic protocols will soon incorporate radiation-

dose–management features.

Worklists with advanced filtering and real-time faceting/subfiltering have led to a major restructuring of daily workflow, with turnaround times decreasing by more than 40%. Radiologist collaboration has increased, and instant access to search engines embedded within the reading environment—which instantly search the entire archive of historical reports— yields more rapid, reliable data mining for research projects.

Searches that formerly required several hours and the creation of dedicated reports now are accomplished by radiologists and house staff in seconds. The integration of a teaching-file tool with the ability to capture key images and text easily from reports and to index each case with either free-text keywords or RadLex™ greatly facilitates the creation of teaching files.

Conclusion: A customized, integrated layer on top of best-of-breed underlying systems has provided NYU Langone Medical Center’s department of radiology with optimized functionality in the areas of workflow, communications, and analytics. In addition, the architecture of this solution allows for customization, rapid change, and growth.

Jon Copeland is CEO of Inland Imaging Business Associates in Spokane, Washington.

A Balanced Workload Like many large radiology practices, Inland Imaging was struggling to balance workloads across groups and varied locations, to meet increased regulatory requirements for proof of quality, to respond to shifting payment models, and to increase the productivity of the partners.

Beginning in 2006, Copeland began work on a streamlined, data-rich, Web-based workflow system that integrates with any RIS or PACS. “We started work in 2006 and did the implementation in 2008 and 2009,” he says of the practice’s enhanced communications system.

It was time well invested. In addition to other benefits, radiologist workloads are now distributed far more equitably, and workflow is smoother. Moreover, while Copeland considers the project

to be complete, enhancements and the addition of features are ongoing. “We sold the system to a vendor, and it is doing great things with it that were beyond our abilities—like DICOM enhancements and other decision-support and office-based patient systems that we want or need, but did not have the capacity to build ourselves,” Copeland notes.

Winning Entry 5 Problem: There was a need for an improved IT workflow infrastructure with intelligence beyond that of any single PACS, RIS, HIS, or other system, along with a need to provide a Web-based form that technologists and others could use to submit updates.

Solution: A streamlined, data-rich, Webbased workflow system was developed to function in multispecialty clinics, rural hospitals, major tertiary-care hospitals, and the practice’s imaging centers. The same workflow system and common subspecialized worklists are used for and by all technologists, radiologist assistants, dispatchers, and radiologists.

A three-tiered worklist allows a specific work assignment to be made to an individual radiologist, a shared subspecialty worklist, or a catch-all worklist for general-radiography exams.

The system can track work RVUs, and we developed our own algorithm for daily equivalency of work performed.

Technology: The system uses Microsoft® .NET components and resides on a single independent server, integrated via our own interface engine. It is built on and supported for the Microsoft platform. It is designed to integrate with any RIS/PACS that supports integration.

Results: Since implementation, we have seen a 14% improvement in radiologist productivity. The ability to balance workloads quickly across the system has dramatically reduced variation in the work performed by radiologists. Before implementation, we had more than a 50% daily variation in work in some subspecialties. Variation is now less than 10%.

The system includes a scheduling and credentialing component that knows everything about our radiologists, including their subspecialties and what shifts they can work, in which cities.

The system improves productivity, and there are quality-tracking functions. Our report-turnaround times have improved significantly due to our ability to balance workloads and identify exams by urgency category (routine, urgent, emergency, or stroke).

There is also a peer review, based on ACR standards, within the workflow system. We perform both retrospective and prospective peer review. The system helps to optimize technology investment and drive clinical and operation results that make a difference. Our radiologists have benefited from a balanced workday and from increased productivity, and they no longer waste time on administrative issues.

Conclusion: The rules of radiology are changing and will continue to change. It is critical, as a radiology group, to provide added value—including workflow systems—in addition to having accurate data to measure productivity and quality.

The Judges These SIIM members scored the entries in the Top Five Medical Imaging IT Projects competition.

Raymond J. Geis, MD, is a radiologist with Advanced Medical Imaging Consultants, PC, Fort Collins, Colorado, and is chair-elect of the SIIM board of directors.

David S. Hirschorn, MD, is director of radiology informatics in the radiology department at Staten Island University Hospital in New York and is a member of the SIIM education committee.

Woojin Kim, MD, is a radiologist in the department of radiology at the University of Pennsylvania School of Medicine in Philadelphia and is a member of SIIM annualmeeting program committee, 2011–2014.

Elizabeth A. Krupinski, PhD, FSIIM, is a research professor in the department of radiology physics at the University of Arizona in Tucson and is chair of the SIIM board of directors.

Christopher D. Meenan, CIIP, is director of clinical information services in the department of radiology at the University of Maryland Medical System in Baltimore and is treasurer of the SIIM board of directors.

James T. Whitfill, MD, is CIO, information services, at Scottsdale Medical Imaging in Arizona and is a member of the Journal of Digital Imaging editorial board.

www.imagingbiz.com | June/July 2011 | Radiology Business Journal 43

Everyone notices when you are successful. Care delivery gets better. Business operations get better. But how do you achieve “better” in light of current challenges? Increasing patient care demands and resource utilization.

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Office-based Practice | Interventional Radiology

The Lure and the Legend of Office-based Interventional Radiology Although they encounter many obstacles, interventional radiologists continue to respond to the siren call of office-based practice, and some believe that the timing has never been better By Karen Roberts

B

y the nature of their subspecialty, interventional radiologists are enamored of innovations that engender emerging minimally invasive therapies, and the 2011 annual meeting of the Society of Interventional Radiology (SIR) in Chicago, Illinois, did not disappoint. Interventional-radiology researchers reported promising outcomes from clinical trials for stroke therapy, multiple-sclerosis treatment, and catheterbased treatments for hypertension.

“New emerging therapies will define interventional radiology,” Timothy P. Murphy, MD, FSIR, told attendees of “Freestanding IR: Economics, Politics, and Business of IR: A Mini MBA,” on March 26. Murphy is the newly inducted president of SIR, medical director of the Vascular Disease Research Center of Rhode Island Hospital in Providence, and a professor at Brown Medical School.

Traditionally, interventional radiologists have delivered their services in hospital settings, often unbeknown to patients with stroke, gastrointestinal bleeding, gunshot wounds, and obstetric emergencies. A growing number of interventional radiologists, however, seek the autonomy to control their own destinies—outside the confines of the hospital—in freestanding clinics.

During a half-day businessdevelopment session that described the pros and cons of freestanding interventional-radiology clinics, no clear model emerged, and many caveats were voiced. Business strategists, for instance, caution interventional radiologists (and their diagnostic-radiology partners)

to remember that the hospital is a very important customer, much as the referring physician is. Murphy notes that the hospital delivery model is not absolutely essential, though it is very important.

A market is emerging, nonetheless, for the outpatient delivery of interventional services as discriminating patients want to know how minimally invasive treatment alternatives compare (in price and outcomes) with surgery or medication.

These patients often have debilitating or life-threatening diseases that have not improved in response to other therapies.

An Independent Streak According to the 17 presenters of the half-day symposium, interventional radiologists gravitating to the freestanding setting prefer the flexibility to schedule patients, to define their case mixes, and work from central offices. Many minimally invasive procedures, however, still require inpatient admission, so whether they work as independent practitioners or in hospital–radiologist joint ventures, more and more interventional radiologists seek the opportunity to meet patients and counsel them about treatment options

www.imagingbiz.com | June/July 2011 | Radiology Business Journal 45

Office-based Practice | Interventional Radiology

Currently, patients with ambulatory conditions go to the hospital, but hospitals are designed for acute care.

In contrast, an interventional-radiology office should be designed for convenient access and patient comfort, and should have a well-trained office staff.

—Timothy P. Murphy, MD, FSIR Rhode Island Hospital

before their procedures and to follow them throughout their therapy regimens.

The greatest challenge for a freestanding interventional-radiology clinic, Murphy says, is to break even—which might be as simple as adding a new procedure that will take the operation into the black. The first challenge, however, will be to overcome the interventionalist’s reputation as a therapeutic technician and win the confidence of referrers and patients for evaluation/management expertise.

If the interventional radiologist isn’t ready to go solo, another option is a joint venture with the hospital. “Everyone benefits,” Murphy says. “Currently, patients with ambulatory conditions go to the hospital, but hospitals are designed for acute care. Parking isn’t good. In contrast, an interventional-radiology office should be designed for convenient access and patient comfort, and should have a well-trained office staff.”

In those scenarios in which an interventional radiologist is employed by the hospital, the hospital typically designates the interventional-radiology budget as a subcost and manages downward, Murphy notes. In this case, interventional radiology is considered an ancillary service, is often operating under capacity, and is most likely to need resources. When a progressive hospital executive sees interventional radiology as a growth area and collaborates with the interventional radiologist in the development of new services, however, investment can follow—and a joint venture can evolve.

In the end, hospitals might not recognize the subsequent procedures that stem from interventional-radiology

services, nor might they be tracking those data. Murphy explains that SIR is actively working to document the return on investment of interventionalradiology services. Moving forward with a freestanding interventional-radiology center or a joint-venture outpatient clinic requires interventional radiologists to document how the investment will generate downstream procedures.

The Patient-safety Mandate Bret Wiechmann, MD, is a member of Vascular & Interventional Physicians (Gainesville, Florida), a subgroup of five interventional radiologists within the 21radiologist Doctors Imaging Group. He addressed the safety spectrum associated with interventional-radiology procedures.

His group is affiliated with two hospitals, and it has an outpatient interventionalradiology clinic and a solely owned imaging center.

“Freestanding interventional radiology is a portable concept,” Wiechmann explains. “With that comes a selfawareness that safety is on the frontline— should we be doing these procedures in an outpatient center, and is this safe and effective? For the most part, yes: We have protocols that arrange for patients to be transferred, if needed.”

Because of the safety issues, the scheduling process in the freestanding center is critical. “We can’t overcommit,” Wiechmann says. “We need to schedule time to review the biopsy results and necessary images.” There is no official accreditation process for outpatient interventional-radiology facilities, but Wiechmann’s group has quarterly safety and quality-assurance meetings.

“Limitations are defined by CMS and

46 Radiology Business Journal | June/July 2011 | www.imagingbiz.com

insurance reimbursements, as well as case complexity,” Wiechmann notes.

“Patient selection becomes key in the outpatient facility. To have an optimum interventional-radiology service, safety demands a strong quality-assurance system.”

Wiechmann continues, “If the interventional radiologist is hospital based, he or she may feel like an interventional radiologist in a box. The hospital assigns the interventional radiologist the procedure based on the procedure, not the patient. In this scenario, the interventional radiologist becomes more of a procedure technician than a consultant, and that is unlikely to change.”

Three steps are critical to the freestanding-clinic model, he says. First, since the interventional radiologist can treat so many organs, he or she has to communicate with all physician specialty groups. Second, the larger radiology group must establishing the legitimacy of its relationship with the freestanding interventional-radiology clinic, requiring buy-in from diagnostic partners. Third, it takes one-on-one meetings with the patient to demonstrate that the interventional radiologist is not just a technician.

Taking the Plunge While the best-laid plans are, after all, just plans, Jeremy Friese, MD, MBA, of the Mayo Clinic (Rochester, Minnesota) impressed on attendees that development is not a static process; interventional radiologists must be willing to make adjustments and respond to changes in the market as their businesses develop.

Case mix and insurance adjustments are unpredictable factors in the road to revenue generation, and the best products and services still need to be enhanced by customer-service excellence.

Ted Chambers, MD, started his own freestanding interventionalradiology center in White Plains, New York (American Access Vascular & Interventional–Westchester), after initially practicing in a highly specialized radiology practice in the Washington, DC, area. He interviewed various partners and later affiliated with a nationwide company that provides operational support and economies of scale. He weighed the

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Office-based Practice | Interventional Radiology

I feel better this year than in past years about the future of freestanding interventional-radiology centers.

—Katherine Krol, MD Indiana University Health Arnett Hospital

pros and cons of starting a freestanding interventional-radiology center; he says that he is challenged on a daily basis, but feels that this model brings satisfaction because he can do better work and still have autonomy.

“When I give a clinical report on a patient to the referring physician, the physician is surprised, asking, ‘Excuse me, what is your specialty?’” Chambers notes. “Physicians are not used to having an interventional radiologist speak so clinically.” He adds that many physicians appear to see interventional radiologists merely as the people who place peripherally inserted central lines.

Chambers advises those following in his entrepreneurial footsteps to take a case-mix inventory often and to communicate continuously with their customers (including hospital executives, radiology-group colleagues, referring physicians, and patients). “This venture is not for the faint-hearted,” he says.

“Once you move to a freestanding center, competitors will be watching.”

Chambers continues, “Young interventional radiologists need the experience that comes from being part of a dynamic hospital setting and a radiology group. Some of us are well suited for the hospital environment, some have more leadership potential, and some are fiercely independent. For me, it was about growing; for others, it’s more about preservation. Do you have control over your schedule? Do you like the cases you are doing?”

When William H. Julien, MD, founded South Florida Vascular Associates in 2001, he was one of the first interventional radiologists to establish an office-based clinical practice in the United States. By 2005, his group had opened the only office-based endovascular suite in the South Florida area.

In 2010, the group opened a new 8,000–square-foot facility, in Coconut Creek, with multiple endovascular suites; 95% of the practice’s interventionalradiology procedures are now done at this freestanding center. While there are 74 interventional radiologists practicing in the South Florida region, those in Julien’s group operate in what continues to be the only freestanding clinic in the region that provides a broad spectrum of services.

As consolidation sweeps health care and hospitals gain greater clout, Julien warns interventional radiologists against overspecialization and relying too heavily on any one referrer. If interventional radiologists provide only a small range of procedures, they are more vulnerable to market forces. For example, Julien is known for his expertise in treating gangrene.

“Don’t rely on the vascular surgeon to feed you,” he says. “Being too limited—or too gifted—may number the days of the interventional-radiology practice.”

A Hybrid Model Paramjit (Romi) Chopra, MD, described a hybrid outpatient interventional-radiology model that he has established at the Midwest Institute for Minimally Invasive Therapies (Melrose Park, Illinois). This metropolitan Chicago physician works hard at serving patients through the community hospital system while maintaining an office-based clinical practice. Chopra’s multispecialty group includes interventional radiologists and vascular surgeons who provide the full spectrum of consulting, procedural, and follow-up services, in both hospital and outpatient settings.

“It’s a changing landscape for physicians,” Chopra says. “With national and state health-care reforms looming, physicians need to change to demonstrate

48 Radiology Business Journal | June/July 2011 | www.imagingbiz.com

that they can reduce the waste (if not literally, then figuratively) in our healthcare system. Interventional radiologists respond with the SIR mantra (quicker, better, safer), but when negotiating with hospitals, interventional radiologists will need to validate how they can make these services faster, better, and cheaper.”

Chopra likens the physician practice to a sports franchise moving from owner players to employee players. In these player negotiations, the interventional radiologist can demonstrate that in many cases, interventional radiologists are the biggest patient admitters to the hospital.

If that sounds surprising, Chopra advises, track the case mix, share it with the hospital, and one of two things will happen: The hospital either will employ the interventional radiologist directly or will partner with the radiology group that employs interventional radiologists.

“In either case, if interventional radiologists can bring their specialized care to a community hospital, the patients don’t need to be transferred.” Chopra says, noting that this is the key. “If the patient is transferred to a large tertiary center, he or she generally doesn’t come back,” he says.

A hallmark of Chopra’s interventionalradiology practice is providing follow-up consultations for the 16,000 patients seen in hospital and clinic settings annually. “I try to be a physician’s physician, working closely with primary-care providers and letting them know that alternative treatments exist,” he says. “That effort puts us higher on the food chain.

To have a successful interventionalradiology practice (whether freestanding, independent, or hybrid), be a physician first: Talk to and know your patient.”

Barry Katzen, MD, FACR, FACC, FSIR, founder and medical director of the Baptist Cardiac & Vascular Institute (Miami, Florida), believes that office-based interventional-radiology practices can exit within (and benefit) radiology group practices, although many interventional radiologists believe that their patient-care contributions are not fully appreciated by diagnosticradiologist colleagues, who are typically focused on throughput and productivity.

To the patient, the interventional radiologist has intrinsic value, Katzen

says. “We provide a less-invasive solution to a severe problem,” he adds.

Aligning With the National View Katherine Krol, MD, of Indiana University Health Arnett Hospital (Lafayette, Indiana), represents SIR on CPT® and CMS matters. She believes that the trend favoring freestanding interventional radiology aligns well with the current health-care environment.

“I feel better this year than in past years about the future of freestanding interventional-radiology centers,” she says. “When interventional radiologists started doing interventions, procedures were done for inpatients, but in the past 10 years, advances in minimally invasive medicine have safely enabled interventional radiologists to access sites in the body with much smaller incisions (using microcatheters and the like).”

She adds, “Some of these procedures can safely be done on an outpatient basis, but safety is correlated with everything we can do. People want to know what happens if you have a code or a complication, and the patient has to be sent to the emergency department. For this reason, the SIR Foundation is actively collecting data to provide guidance about procedures that are best suited for freestanding centers.”

The SIR Foundation is continuing to collect documentation and to review every CPT code for effective, safe performance in a freestanding interventional-radiology setting.

In the beginning, if a radiology group had a freestanding facility, each facility typically contracted independently with non-Medicare insurance carriers. This laborious process deterred many from developing a successful freestanding model. Today, more and more interventional radiologists are clearing such hurdles by contracting through hospitals and radiology group practices.

Documenting safe and effective care and managing the relevant data are essential, she adds.

“Currently, there is no accreditation process for freestanding interventionalradiology centers, and there is no repository where physicians can provide information,” she notes, “but if the hospital has established the freestanding center,

there should be an oversight process for the safety of the outpatient center—and an opportunity to collect data to support the CPT and CMS processes. CMS is asking very good questions that may evolve into CMS policy, but that policy doesn’t exist yet.”

Carrier negotiations represent another hurdle for office-based interventional radiology. “There are a number of procedures we haven’t gotten payment for,” Krol says. “If we’re celebrating a 10-year anniversary, then certainly,

interventional radiologists have made progress on all three fronts. The future of freestanding interventional radiology is in the hands of entrepreneurial interventional radiologists who are willing to navigate these hurdles, much as they navigate the vasculature, on a daily basis. It’s tough, but they persevere, knowing that the delivery of better, faster, safer medicine is possible.”

Karen Roberts is a contributing writer for Radiology Business Journal.

Quantifying Interventional Radiology’s Tangible Value

I

n recent years, interventional radiologists have had an easier time with the long-standing challenge of impressing their diagnostic colleagues with the intangible worth of a clinical interventional-radiology service. A radiology practice with clinical feet on the street has at least a fighting chance of outrunning a remote teleradiology service.

Gregory Soares, MD, director of interventional radiology at Rhode Island Hospital in Providence and a member of the megapractice Rhode Island Medical Imaging (RIMI) in Providence, took this mission a step further and devised a system for quantifying clinical interventional radiology’s tangible value. He shared the model that he used to measure interventional radiology’s contribution to practice RVUs at the Annual Summit of the RBMA in New Orleans, Louisiana, on June 6, 2011.

“Diagnostic imaging groups devalue—and should—evaluation/management services,” Soares says. During the half hour that an interventional radiologist spends on an initial evaluation/management visit, which is worth 3.93 RVUs in the 2009 Medicare Physician Fee Schedule (MPFS), a diagnostic radiologist can read four noncontrast brain CT exams (worth 6 or more RVUs in the 2009 MPFS). The value, he continues, is not in the initial episode of evaluation/management; it is the downstream revenue generated by the clinical contact.

The tangible value of a clinical interventional-radiology service includes direct revenue generation (procedural and evaluation/management reimbursement) and indirect revenue generation (imaging and downstream imaging) that Soares calls the ripple effect.

Barriers to Clear Soares emphasizes that anyone interested in applying the algorithm first needs to establish certain measurement assumptions.

In order to identify the interventionalradiology revenue bucket, the practice must define what interventional radiology is in the practice. “Is it the interventional radiologists in the fluoroscopy suite, doing traditional interventional-radiology procedures, or does it include the people down in CT and ultrasound, doing biopsies and drainages?” he asks. “Are ablations interventionalradiology procedures?”

For the purpose of understanding the costs of the interventional-radiology program, a practice must identify those radiologists who do interventional procedures. This could be restricted to radiologists defined as interventional radiologists or could include all radiologists with interventional-radiology fellowships, those who have a certificate of added qualification in interventional radiology, or anyone who puts a needle in a patient.

In order to perform appropriate assignment of the dollars attributed to interventional radiology, a practice must establish a revenue center that is a hospitalbased revenue center, a modality revenue center, an office-based revenue center, or a combination of all three. In a complex practice such as Soares’ environment, this can be challenging, but it is not impossible.

Other requisite tools include people with interventional-radiology coding expertise; a billing program with basic data-mining capabilities (for instance, the ability to identify procedures by patient and define where this work was done); someone in the

www.imagingbiz.com | June/July 2011 | Radiology Business Journal 49

Office-based Practice | Interventional Radiology

The numbers I shared with you bore out that 50% of the revenue was indirect. This algorithm requires identification of the initial clinical contact.

—Gregory Soares, MD Rhode Island Hospital IT department who is willing to perform the searches; and time.

The Algorithm This algorithm is based on indexing the CPT® codes that define the patient’s initial clinical contact with your group during the time frame under investigation—2008, in the case of RIMI. With subsequent queries of the data, it is possible to identify the downstream revenue that each of those clinical contacts generates and to eliminate codes that are not attributable to the interventional-radiology practice.

In preparation for applying the algorithm, compile an exhaustive list of the interventional-radiology codes for your practice, including everything that your interventional radiologists do and nothing that your interventional radiologists don’t do. For RIMI, that added up to 708 distinct codes, including procedural and evaluation/ management codes. “This is what you are going to use to probe your group’s billing data,” Soares says.

Query 1: This first query of the database defines all interventional-radiology charges

performed during a designated time period, including all charge codes submitted for interventional-radiology procedures and evaluation/management work. It provides an initial list of interventional-radiology procedures, as well a list of all evaluation/ management codes representing first patient visits and follow-up visits that occurred during that year.

In subsequent queries, these will mark starting points for evaluations of downstream work generated by those visits.

The result is the interventional-radiology direct revenue, which totaled 17,607 RVUs for RIMI in 2008 (see table).

Query 2: The second query dives into that initial direct worklist to identify the initial patient visit codes, including many of the 99000 codes. Those initial visits are flagged to identify indirect revenue generated in caring for those patients in subsequent visits.

Query 3: The final query will define indirect revenue generated subsequent to follow-up evaluation/management (indicated by CPT codes 99211–99215 and 99231–99238). By pulling the patient identifiers, a list of subsequent visits/

Table. Initial Clinical Interventional-radiology Contacts (Procedure or Evaluation/Management), 2008

Setting Procedures and Evaluation/Management Academic Hospital Emergency department......................................................................... 66 Outpatient........................................................................................ 4,085 Inpatient.......................................................................................... 6,933 Subtotal.......................................................................................... 11,084 Clincal Office......................................................................................... 2,048 Affiliate Hospital Emergency department.......................................................................... 71 Outpatient......................................................................................... 1,875 Inpatient.......................................................................................... 2,529 Subtotal........................................................................................... 4,475 Total...................................................................................................... 17,607 50 Radiology Business Journal | June/July 2011 | www.imagingbiz.com

procedures for each patient is generated from which all of the downstream revenue can be identified.

Indirect-revenue Filter Of course, not all subsequent visits can be attributed to the interventional-radiology revenue bucket, which is why a two-part filtering process is necessary, The first part is automated and relatively painless: It involves filtering out those procedures that interventional radiologists don’t do, such as mammography, dual-energy x-ray absorptiometry, and breast biopsy.

The manual filter component is exactly that: Someone who understands the coding process must look through the data and eliminate the codes that are not relevant.

Soares used the example of the patient who initially presented with menorrhagia. Under that person’s identifier, all of the subsequent work for that patient done by the group is listed, including codes for uterine artery embolization, a pelvic MRI exam, follow-up evaluation/management, a CT exam of the abdomen, and a chest radiograph. The first three are clearly related, but the last two are atypical procedures following uterine artery embolization. They are eliminated from the interventional-radiology revenue-center pool.

The final tally delivered the following totals for the RIMI interventional-radiology revenue center in 2008: Direct interventionalradiology RVUs (procedures and evaluation/ management), 87,251 (50%); indirect interventional-radiology RVUs (due to new patient evaluation/management): 62,256 (35.7%); indirect interventional-radiology RVUs (due to established patient evaluation/ management): 24,794 (14.3%); and total interventional-radiology RVUs: 174,304.

Soares was suitably impressed with that total until he had to demonstrate return on investment to his group, and the number fell a bit short. He notes that the picture has changed substantially since 2008.

In conclusion, Soares emphasizes the importance of identifying the patient starting point, which (in turn) reveals the indirect component of the interventional-radiology revenue pool. “The numbers I shared with you bore out that 50% of the revenue was indirect,” he says. “This algorithm requires identification of the initial clinical contact: That’s how we find the starting point for all of the ripples that come out of interventional radiology.”

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Performance Analytics | Billing

Performance Analytics: What Billing Can Tell You

Whether a practice uses in-house or outsourced billing, attention to key matrices will keep the organization on a profitable path

By Felix Okhiria, MPA, MA, CCPO, CMPE, CPC, CHC

M

edical billing is the process of translating a physician’s work into reimbursable language understood by governmental and private third-party payors. The billing process must start with the physician’s documentation of patient encounters, which forms the basis for billing. The physician’s documentation is then translated into a CPT® code (representing the type of work done) and an ICD-9 code (indicating the reason for that work).

In some practices, physicians use encounter forms with preprinted CPT and ICD-9 codes, while other practices derive the billing language (codes) directly from physicians’ documentation.

Medical billing can provide important intelligence on the state of a practice based on charge capture, reconciliation, and lag time; net (or adjusted) collection ratio; days in accounts receivable; and charge/payor mixes.

revenue losses) or overcoding (with the potential for compliance problems). For example, a referring physician might order a CT exam of the abdomen, but the radiology department might determine that a CT exam of the abdomen and pelvis is more appropriate because of the patient’s signs and symptoms.

Under normal circumstances, the

Charge Capture and Reconciliation The charge-capture and -reconciliation matrix is used to assess the efficacy of a billing operation. Charge capture refers to the process of ensuring that all billable services are captured and billed to thirdparty insurance carriers. To be certain that all charges are captured, a physician practice must implement a robust system of reconciling services performed by its physicians with charges billed to insurance carriers.

A radiology practice that bills payors based on exam orders must take care to ensure that billed exams accurately reflect exams performed. Billing based on ordered exams could be fraught with potential undercoding (resulting in 52 Radiology Business Journal | June/July 2011 | www.imagingbiz.com

radiology department would then contact the referring physician to request a new order for a CT exam of the abdomen and pelvis. In some cases, the radiologist and referring physician might verbally agree that a new order for both areas should be procured— without communicating the information to the administrative staff.

In those cases, a practice that bills payors based on referring physicians’ orders might bill only for the CT exam of the abdomen, while neglecting to bill for the additional CT exam of the pelvis (because the original order was not changed to reflect the agreement between the radiologist and the referring physician). A practice with this type of

pattern could be losing a substantial amount of revenue because additional exams, when performed, are not reflected by orders.

The reverse potential (for overcoding) also exists if the practice in question receives an order for a CT exam of the abdomen and pelvis, but decides that only an abdominal CT exam is necessary. If the

order is not changed to reflect that only an abdominal CT exam was performed, the practice could bill for a CT exam of the abdomen and pelvis, resulting in overcoding and a potential compliance problem. A practice that bills payors based on radiologists’ documentation—not referrers’ orders—should be able catch such discrepancies and bill appropriately.

www.imagingbiz.com | June/July 2011 | Radiology Business Journal 53

Performance Analytics | Billing

This is an area that requires clearly defined processes for dealing with changes in ordered exams to make sure that the appropriate exams are billed accurately.

The problem of exam changes affects a broad range of studies; for example, a referring physician might order an MRI exam of the cervical, thoracic, or lumbar spine, but the radiologist might determine that an MRI exam of the total spine is more appropriate for the indication presented by the patient. Unless the order is changed, a

practice that bills based on exams ordered might be likely to bill for one CPT code, as opposed to the three CPT codes that apply to a total-spine MRI exam.

Two of the more common areas where some practices might be leaving money on the table involve changing a noncontrast exam to a contrast exam and changing a contrast exam to a precontrast– postcontrast exam. Since radiology departments can determine when an exam requires contrast administration, a

practice that bills based on orders might be likely to bill for an exam ordered without contrast—even when contrast media are actually administered, based on the clinical judgment of the radiologist.

An effective way to mitigate such billing errors is to set up a process for communicating exam changes to the administrative staff, ensuring that orders for exams properly reflect exams actually performed by the radiologist. In addition to changing the order (after receiving the new order from the referring clinician), the administrative staff must also ensure that the new exam has the appropriate authorization from the insurance carrier, in order to be reimbursed for the exam.

Some utilization-management companies will only reimburse providers for CPT codes that are specifically authorized; they either will not reimburse for an unauthorized exam or will reimburse for it at a significantly lower rate. The processes used to capture and reconcile exams, therefore, speak volumes about the financial health—or the lack thereof—of a practice.

Net/Adjusted Collection Ratio The net (or adjusted) collection ratio involves looking at the relationship between the actual payment collected by medical practices and what they should have collected: The collected amount, divided by the billed amount, yields the percentage representing the adjusted collection ratio. The ratio should indicate the effectiveness of a medical practice’s collections efforts, and it should be a leading barometer of difficulties in the billing processes.

Generally speaking, a practice should aim to collect all that is legitimately and legally due to it, but a 100% collection ratio might be difficult to achieve, depending on the patient population.

Nevertheless, a practice should aim for a net collection ratio of at least 95%. A lower net collection ratio might be an indication that the practice is not being paid at its contracted rates.

To determine whether a practice is being paid the right amount, load the contracted rates into the billing system; it is then easy to determine the accuracy of each payment by matching the payment

54 Radiology Business Journal | June/July 2011 | www.imagingbiz.com

Survey Makes Case For Cloud-based Storage In February, a survey of healthcare IT professionals revealed that more than half are kept up at night by concerns about disaster recovery of medical images. Despite this overwhelming concern, fewer than one-third of respondents report that they comply with HIPAA recommendations for storing images that would enable them to recover from a disaster.

The Survey and Its Key Findings At the annual meeting of the Healthcare Information and Management Systems Society, independent research company Dimensional Research conducted a survey of 568 healthcare IT professionals regarding the storage of medical images, finding that:

4 55% are kept up at night by concerns about disaster recovery, 4 69% report that their image-storage methods do not comply with the image-storage recommendations of HIPAA, and 4 58% either plan to use cloud-based image storage (49%) or already do (9%).

The New Healthcare Information Paradigm The survey and its findings come at a time of great change in healthcare information management. The shift to the electronic medical record and the sharing of digital information are well under way, requiring information to be accessible easily and quickly. In addition, storage requirements for medical images are growing at annual rates of 20% to 40%. New types of information such as outcomes data and business-intelligence information (analytics), not to mention increasing audit logs, are increasingly part of the overall healthcare IT burden.

Demands and Costs Rise According to David Finn, health IT officer for Symantec Corp, these realities combine to make cloud-based storage an obvious and inevitable solution. “Many providers are struggling to maintain their archives,” Finn says. “Studies are more numerous, and they consist of larger files. Then, you have the capital investment in hardware, software licenses, additional floor space, build-outs, cooling needs, electricity requirements, and the personnel to make it all happen and to manage the data center.”

With all of this in mind, Finn says, cloud-based storage can save 25% to 50% in storage costs. In addition, cloudbased storage is well off-site from the primary data center—a best-practice disaster-recovery plan.

More Providers Rely on Cloud-based Storage At its simplest, the cloud is an Internet-based server (or, more accurately, many servers) hosted by a third party. In Sponsored by

its survey, Dimensional Research found that only 9% of respondents are using cloud-based image storage. On the other hand, another 49% said they plan to use the cloud to store medical images. Finn is buoyed by the 9% finding because in 2010, only 1% of healthcare IT professionals said they would use the cloud to store protected health information.

“I think this dramatic increase really points to the issues of cost savings and changing healthcare-information demands,” he says.

Finn also points out that time considerations are a major contributor to the acceptance of cloud-based solutions. “This growth also speaks to the need for imaging centers and practices— and healthcare providers in general—to be more agile. It makes no sense to spend six months implementing something that could be implemented in three days in the cloud.”

For Finn, a major point is that cloud storage isn’t just file keeping; it is infrastructure as a service. In addition to facilitating easy and fast implementation, the cloud also enables IT departments to respond nimbly to business demands, such as purchasing another practice. “You not only have personnel and resources free to focus on the new demand,” Finn says, “but you also remove the complexity of absorbing the IT of the new acquisition. You just point your systems at the data.”

Test the Cloud With the Long-term Archive While Finn expects reliance upon the cloud for storage, one day, to be close to “four nines” (99.99%), he recommends that providers start by using it to store some of their longterm archives. This enables the enterprise to learn how to use the cloud while freeing on-site storage capacity for the shortterm archive. This increases the speed of access for both the short-term local storage and long-term storage (which, with the cloud, would be Internet accessible). They can increase their reliance on the cloud as they become more comfortable with its use and benefits.

The Cloud Can Meet or Exceed All Security Standards As revealed in the survey, 42% of healthcare IT professionals do not see themselves relying on the cloud for image storage.

For this group, the primary concern is security, and it’s a legitimate concern. Finn, however, sees this as an argument for relying on the cloud rather than against it, asserting that the cloud can be made just as secure as, or more secure than, any other data system. “Whatever your organization’s standards for data security, the cloud can meet them,” Finn says.

Finn comes from a position of confidence on this point, as health IT officer for a leader in data security that now offers cloud-based IT infrastructure and data storage. “Protecting data is all that Symantec Corp does,” he says.

Visit www.symantechealth.com

Performance Analytics | Billing

A practice that has good monitoring tools for claim-submission patterns, claim-edit management, and insurance-validation reports should never be surprised—because those tools should predict what to expect with a certain degree of confidence.

—Felix Okhiria, MPA, MA, CCPO, CMPE, CPC, CHC NYU Langone Medical Center

received to the allowed amount in the billing system. A payment amount lower than the contracted rate does not necessarily translate into incorrect reimbursement, since many (if not most) insurance plans now include patient responsibility (in the form of deductibles and copayments).

Thus, to determine whether there has

been an underpayment, a practice must factor in the patient’s responsibilities as well. A lower payment than the contracted payment can also be caused by other factors; these include multiple-procedure rules, under which insurance carriers reimburse for the second and subsequent procedures performed on the same day at less than the contracted rate.

56 Radiology Business Journal | June/July 2011 | www.imagingbiz.com

Once all of the factors that might reduce payments have been filtered out, what remains is an authentic report indicating underpayments. With that in hand, a practice has multiple options for addressing the problem. If the underpayments are insignificant, the practice might elect to apply its usual processes for accounts-receivable management. If the problem appears to be systemic, however, the practice might want to meet with payors to correct it.

If the problem persists after numerous efforts to fix it, the practice might want to consider other remedial approaches.

In many cases, recurring problems of underpayment might be the result of an insurance carrier mistakenly loading the wrong rates into its claims system. It is thus advisable for a practice, after signing a new contract with an insurance carrier, to demand a report from the carrier showing the fees loaded into its system; making sure that these rates are correct will prevent future problems.

Days in Accounts Receivable Days in accounts receivable indicate the length of time that it takes a practice to convert charges or claims into cash.

The matrix is represented mathematically as the total accounts receivable of a practice divided by the average daily charge. A practice must be very careful in setting up this matrix, making sure that the ratio is measuring what it is intended to measure. For instance, including only payor-contracted amounts (not patients’ responsibilities) in daily average charges might artificially increase the apparent days in accounts receivable.

A practice should be aware of the the claims-processing and payment patterns of its insurance carriers so that it can quickly detect a problem—and fix it before it becomes unmanageable.

Many insurance carriers have predictable patterns of claims processing and of determination of the payor’s responsibility (adjudication). For instance, Medicare generally adjudicates claims in 14 days, while many managed-care carriers adjudicate claims in 21 to 30 days.

If charges and claim submissions are constant and consistent, a practice should be able to predict its monthly cash flow

with little variation. If the predicted cash flow deviates from expectation, then the practice should intervene immediately. A practice that has good monitoring tools for claim-submission patterns, claim-edit management, and insurance-validation reports should never be surprised— because those tools should predict what to expect with a certain degree of confidence.

Those tools obviously will not predict insurance errors, but they should help the practice to focus quickly on areas that might be responsible for delayed payments or nonpayment. Days in accounts receivable will tell a practice about systemic billing-process problems, should they exist. Days in accounts receivable that deviate significantly from industry standards should be a red flag, with the problem looked into and addressed quickly.

A higher number of days in accounts receivable than the industry norm could be due to a variety of problems, from demographic and insurance errors at registration to excessive lag time in filing claims with insurance carriers, porous edit-management processes, consistent and constant underpayment, increased or inaccurate claim denials, or excessive delays in posting payments to patients’ accounts. The obvious challenge, for a practice, is to recognize the problems responsible for the increased days in accounts receivable and employ an effective intervention regime to arrest the problem.

If the problem relates to claims that are not getting to the insurance carriers, the practice should take corrective measures by ensuring that charges are entered within an established, reasonable amount of time. It should also ensure that all claims edits from the billing system and insurance carriers are addressed in a timely manner, to make sure that claims are reaching to the insurance carriers in as clean a form as possible.

The practice should monitor payors’ validation reports, which indicate the number of claims submitted and accepted.

At least 95% of a practice’s claims should be accepted on the first submission— and if this is not the case, the practice’s edit-management system might be the

problem. Monitoring days in accounts receivable routinely, and benchmarking that number against industry standards, should be part of the integral billing language that tells a practice whether or not it is heading in the right direction.

Charge/Payor Mixes The charge/payor-mix ratio is a measure of a practice’s patient population and its insurance coverage; it also denotes the relative importance of various sources of revenue. Charge mix refers to the volume of exams and the dollar amount

of charges going out to different insurance carriers, while payor mix refers to the amount and sources of money coming into the practice. Practices that maintain charges at the allowed insurance amounts should have the charge/payor-mix ratio at equivalent proportions (with the exception of written-off bad debts, which will affect the payor mix).

A practice located in an elderly community might attract a significant number of Medicare patients, while a practice located in an economically depressed community might attract more

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Performance Analytics | Billing

Medicaid patients. A practice located in a business district might attract a sizable number of managed-care patients and patients with commercial insurance.

Typically, a practice with more patients who have commercial insurance coverage will probably be more financially stable than a practice that has fewer such patients.

Commercial insurance (indemnity) plans usually pay about 100% of a practice’s charges—or a high percentage of the charges, with the remaining balance defaulting to the patient. These types of plans are rare in areas where managed care dominates the market. Depending on the characteristics of the practice’s market area, the next highest payments can usually be expected from managed-care carriers or negotiated fee-for-service plans.

With managed-care carriers, a practice actively negotiates fees for its services.

The success of such negotiations will depend on a number of factors, such as the leverage that the practice might have, the reputation and expertise of the physicians in the practice, innovative technology, affiliation with a reputable medical institution, and the competitive environment. The negotiated rate might be based on a factor of Medicare or on a set amount per RVU, with a cost-of-living adjustment.

Next in the reimbursement hierarchy in many markets is Medicare. Medicare has the most leverage of all insurance carriers due to the enormous buying power of the federal government. Medicare releases its Medicare Physician Fee Schedule annually, with a set reimbursement per CPT code for participating and nonparticipating physicians. Practices have no negotiating leverage with Medicare and must accept the allowed amount (with Medicare paying 80% of the allowed amount and the patient, or the patient’s secondary insurance, responsible for the other 20%).

Last in the physician-reimbursement hierarchy is Medicaid, which pays very little for physician services. It is not unusual to find practices that do not accept Medicaid because of the low reimbursement. Another component of the charge/payor mix is the self-pay group.

Generally, these are patients who have no

insurance coverage and must therefore pay the practice’s charges (or a negotiated discounted charge). The irony is that this group of patients ends up paying most— if not all—of the physician’s charges because it lacks the bargaining power of insurance plans.

Charge/payor mix is an important barometer of a practice’s financial health.

It can tell a practice where to concentrate its marketing efforts so as to attract a composite payor mix that could enhance the practice’s financial viability and sustainability.

Conclusion Billing can tell us a lot about a practice: how efficiently the practice is running, how financially viable the practice is, and whether resources are being optimized to achieve the goals and objectives of the practice. Above all, the billing matrix should be a barometer for measuring where the practice is—and where it should be.

While billing matrices are not a panacea for all of a practice’s ills, it is fair to suggest that a practice that diligently monitors these measurements should be able to discern changes in patterns (and to take corrective action, when necessary). The monitoring tools become even more important for practices that outsource billing functions. It is vital for them to develop some key matrices that can quickly identify problems before they become unmanageable. Simple matrices, such as average daily cash receipts compared with targeted daily cash, can quickly point to the potential problem, if negative variance persists for longer periods than expected. The same simple matrix can be developed for average daily charges compared with targeted daily charges.

These matrices can (and do) tell practices about their operations—and listening to those words of billing wisdom can be what creates the difference between a successful practice and a struggling practice.

Felix Okhiria, MPA, MA, CCPO, CMPE, CPC, CHC, is director of business services, NYU Langone Medical Center, New York, New York.

58 Radiology Business Journal | June/July 2011 | www.imagingbiz.com

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FinalREAD

Managing Expectations The challenge for practice leaders in the months and years ahead will be to manage expectations based on historic returns By Curtis Kauffman-Pickelle

E

ditor Cheryl Proval and I had the privilege of moderating a very interesting and animated session at the recent RBMA meeting in New Orleans, Louisiana. It was a face-to-face panel discussion with the CEOs of each of the five radiology benefit management (RBM) companies. Anticipation built during the conference, and the attendees were definitely ready for their opportunity to grill these CEOs about what they view as the extremely burdensome processes of preauthorization, which have added costs and workload to their practices.

a suggestion that these five find ways to standardize their processes for the sake of efficiency in the imaging profession.

Kudos to the RBMA for building a framework for conversation with the RBMs, for having the foresight to assemble these leaders, and for providing a forum for a meaningful exchange. Although there was wide disagreement on several of issues, it was apparent that both the RBM organizations and the practices/centers represented by those in attendance are seeking solutions that will protect the status and efficacy of radiology practices, as ever more scrutiny and pricing pressure emerge from the payors.

It became very clear, as the CEOs delved deeper into the rationale for some of their

The second statistic discussed among thought leaders was that the most likely reduction in professional-fee reimbursement in the next five years will be 30%: a double whammy.

Each panelist was gracious and accommodating in responding to questions, and apart from a very few attendees who rather pointedly took issue with what the panelists had to say, the audience was respectful; it provided intelligent perspectives on the dilemma of how best to control rising costs in medical imaging.

Brandon Cady, CEO of American Imaging Management (Deerfield, Illinois); Curt Thorne, CEO of MedSolutions (Franklin, Tennessee); Cherrill Farnsworth, CEO of HealthHelp (Houston, Texas); Thomas Dehn, MD, CMO of National Imaging Associates (Avon, Connecticut); and Donald Ryan, CEO of CareCore National (Bluffton, South Carolina) fielded a variety of topics and questions that were designed to shed light on the business model, value proposition, processes, and role of RBMs in a health-care arena under extreme pressure to manage imaging utilization. Although they are competitors with each other, there was consensus among the five that the radiology managers had some very good points—chief among them,

preauthorization processes, that they are acting on behalf of the insurance-company payors for which they are the administrator/ vendor for the benefit. Their target is the primary-care practitioner, and the majority seemed supportive of the diagnosticimaging value proposition.

One point among many caught my particular attention. In response to a rather heated debate about the impact of RBMs on practice economics, Dehn said that the biggest challenge facing radiology practice managers, administrators, and CEOs, in the coming years, will be how best to manage the expectations of the radiologists within their practices. This is in light of the perfect storm of economic changes headed their way.

A couple of statistics that were discussed throughout the day added impact to that statement. One was that there is consensus on the notion that some 20% to 40% of imaging studies are unnecessary—and that is where the RBMs focus their attention and target their reductions. The second statistic discussed among thought leaders was that

60 Radiology Business Journal | June/July 2011 | www.imagingbiz.com

the most likely reduction in professional-fee reimbursement in the next five years will be 30%: a double whammy.

The view among payors is that a significant portion of imaging is wasted money, and they—in addition—plan on continuing to ratchet down payments for professional fees over the next several years.

Given these two huge changes to the economic portrait of the radiology practice, Dehnisabsolutelyright:Thebiggestchallenge will be to find how best to understand the impact, to manage expectations among those currently oblivious to this reality, and to take actions, now, that will protect the enterprise for the long term. How can you enhance productivity? What efficiencies can be gained? How can you increase revenue, build customer loyalty, gain market share, and eliminate internal strife? How can you align all of the stakeholders around the idea that everyone will need to be a part of the survival solution?

All of this (and more) will be required, if these predictions are correct. In addition, after listening carefully to the viewpoints of the RBM executives and considering the enormity of the task for providers and payors in eliminating waste and taking cost out of the system, it seems to me that finding ways to communicate and work with the RBMs, in a collaborative effort, could be a step in the right direction.

Given the significant strides made by those companies that have developed decision-support software and systems, the possibility now exists for practice managers— represented by the RBMA, the decisionsupport developers, and the RBMs—to continue the meaningful dialogue that was started in New Orleans. There seemed to be genuine interest in the idea of building on this process, and that is very encouraging.

Now, the task will be determining how best to manage everyone’s expectations.

Curtis Kauffman-Pickelle is publisher of ImagingBiz.com and Radiology Business Journal, and is a 25-year veteran of the medical-imaging industry.

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