Association and Trends in Medicare Denials and Utilization for Brain CT: Indirect Impacts by Targeted Policy Intervention?

Twenty-five years of annual Medicare Physician/Supplier Procedure Summary (PSPS) Master File data were used to assess trends in normalized volume and claim denial rates for brain computerized tomography. Alongside growth in utilization of brain computerized tomography (services, denial rates, fell from 1999-2005 and with relatively leveled growth and less denial rate volatility thereafter. More recent trends in denial rates may be related to policy interventions initially aimed at cost and volume reduction.

Increased per-patient imaging utilization in an emergency department setting during COVID-19.

INTRODUCTION: COVID-19 has resulted in decreases in absolute imaging volumes, however imaging utilization on a per-patient basis has not been reported. Here we compare per-patient imaging utilization, characterized by imaging studies and work relative value units (wRVUs), in an emergency department (ED) during a COVID-19 surge to the same period in 2019. METHODS: This retrospective study included patients presenting to the ED from April 1-May 1, 2020 and 2019. Patients were stratified into three primary subgroups: all patients (n = 9580, n = 5686), patients presenting with respiratory complaints (n = 1373, n = 2193), and patients presenting without respiratory complaints (n = 8207, n = 3493). The primary outcome was imaging studies/patient and wRVU/patient. Secondary analysis was by disposition and COVID status. Comparisons were via the Wilcoxon rank-sum or Chi-squared tests. RESULTS: The total patients, imaging exams, and wRVUs during the 2020 and 2019 periods were 5686 and 9580 (-41%), 6624 and 8765 (-24%), and 4988 and 7818 (-36%), respectively, and the percentage patients receiving any imaging was 67% and 51%, respectively (p < .0001). In 2020 there was a 170% relative increase in patients presenting with respiratory complaints. In 2020, patients without respiratory complaints generated 24% more wRVU/patient (p < .0001) and 33% more studies/patient (p < .0001), highlighted by 38% more CTs/patient. CONCLUSION: We report increased per-patient imaging utilization in an emergency department during COVID-19, particularly in patients without respiratory complaints.

Impact of PET/MRI in the Treatment of Pancreatic Adenocarcinoma: a Retrospective Cohort Study.

PURPOSE: Imaging is central to the diagnosis and management of Pancreatic Ductal Adenocarcinoma (PDAC). This study evaluated if positron emission tomography (PET)/magnetic resonance imaging (MRI) elicited treatment modifications in PDAC when compared to standard of care imaging (SCI). PROCEDURES: This retrospective study included consecutive patients with PDAC who underwent 2-deoxy-2-[18F]fluoro-D-glucose ([18F]F-FDG) PET/MRI and SCI from May 2017 to January 2019. SCI included abdominal computed tomography (CT), MRI, and/or PET/CT. For patients who had more than one pair of PET/MRI and SCI, each management decision was independently evaluated. Treatment strategies based on each modality were extracted from electronic medical records. Follow-up was evaluated until January 2020. RESULTS: Twenty-five patients underwent 37 PET/MRI's, mean age was 65 ± 9 years and 13 (13/25, 52 %) were men. 49 % (18/37, 95 % CI 33-64 %) of the PET/MRI scans changed clinical management. Whether the SCI included a PET/CT or not did not significantly modify the probability of management change (OR = 0.9, 95 % CI 0.2-4, p = 1). One hundred percent (33/33) of the available follow-up data confirmed PET/MRI findings. CONCLUSIONS: PET/MRI significantly changed PDAC management, consistently across the different SCI modalities it was compared to. These findings suggest a role for PET/MRI in the management of PDAC.

Changes in Current Procedural Terminology Coding and Its Effect on Specialty-Level Utilization of Musculoskeletal Ultrasound.

PURPOSE: Concerns regarding increasing utilization of non-vascular extremity ultrasound (US) imaging led to the Current Procedural Terminology (CPT) Editorial Panel separating a singular billing code into distinct comprehensive and focused examination codes with differential reimbursement. We explore this policy change's temporal association with utilization. METHODS: Using Physician/Supplier Procedure Summary Master Files, we identified all nonvascular extremity US services billed for Medicare fee-for-service beneficiaries between 1994 and 2017. These included generic (CPT code 76880 from 1994 to 2010), complete (code 76881 from 2011 to 2017), and limited (code 76882 from 2011 to 2017) examinations. Annual utilization per 100,000 beneficiaries was computed and stratified by billing specialty. Compound annual growth rates were calculated. RESULTS: Radiologists and podiatrists were the top 2 billing specialties for nonvascular extremity US examinations. From 1994 to 2010, radiologist services increased 6.1% annually. Following the 2011 code separation, radiologists' utilization increased 2.7% annually for complete and 12.3% for limited exams. Between 1994 and 2017, radiologists' market share decreased 72.8% to 40.4%. From 1994 to 2010, podiatrist services increased 87.1% annually. Following the code separation, podiatrists' annual utilization growth stabilized 0.4% for complete and 0.6% for limited exams. Podiatrists' market share was 9.1% in 2001, peaked at 31.3% in 2009, and declined to 14.3% in 2017. CONCLUSIONS: Prior rapid growth in extremity nonvascular US for podiatrists slowed considerably following CPT code separation in 2011. Subsequent service growth has largely been related to less costly, focused examinations performed by radiologists. Further study may help better understand how CPT coding changes alter imaging utilization more broadly.

Abdominal Imaging Findings in COVID-19: Preliminary Observations.

Background Angiotensin-converting enzyme 2, a target of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), demonstrates its highest surface expression in the lung, small bowel, and vasculature, suggesting abdominal viscera may be susceptible to injury. Purpose To report abdominal imaging findings in patients with coronavirus disease 2019. Materials and Methods In this retrospective cross-sectional study, patients consecutively admitted to a single quaternary care center from March 27 to April 10, 2020, who tested positive for SARS-CoV-2 were included. Abdominal imaging studies performed in these patients were reviewed, and salient findings were recorded. Medical records were reviewed for clinical data. Univariable analysis and logistic regression were performed. Results A total of 412 patients (average age, 57 years; range, 18 to >90 years; 241 men, 171 women) were evaluated. A total of 224 abdominal imaging studies were performed (radiography, n = 137; US, n = 44; CT, n = 42; MRI, n = 1) in 134 patients (33%). Abdominal imaging was associated with age (odds ratio [OR], 1.03 per year of increase; P = .001) and intensive care unit (ICU) admission (OR, 17.3; P < .001). Bowel-wall abnormalities were seen on 31% of CT images (13 of 42) and were associated with ICU admission (OR, 15.5; P = .01). Bowel findings included pneumatosis or portal venous gas, seen on 20% of CT images obtained in patients in the ICU (four of 20). Surgical correlation (n = 4) revealed unusual yellow discoloration of the bowel (n = 3) and bowel infarction (n = 2). Pathologic findings revealed ischemic enteritis with patchy necrosis and fibrin thrombi in arterioles (n = 2). Right upper quadrant US examinations were mostly performed because of liver laboratory findings (87%, 32 of 37), and 54% (20 of 37) revealed a dilated sludge-filled gallbladder, suggestive of bile stasis. Patients with a cholecystostomy tube placed (n = 4) had negative bacterial cultures. Conclusion Bowel abnormalities and gallbladder bile stasis were common findings on abdominal images of patients with coronavirus disease 2019. Patients who underwent laparotomy often had ischemia, possibly due to small-vessel thrombosis. © RSNA, 2020.

Changing Utilization of Noninvasive Diagnostic Imaging Over 2 Decades: An Examination Family-Focused Analysis of Medicare Claims Using the Neiman Imaging Types of Service Categorization System.

OBJECTIVE: The objective of our study was to use a new modality and body region categorization system to assess changing utilization of noninvasive diagnostic imaging in the Medicare fee-for-service population over a recent 20-year period (1994-2013). MATERIALS AND METHODS: All Medicare Part B Physician Fee Schedule services billed between 1994 and 2013 were identified using Physician/Supplier Procedure Summary master files. Billed codes for diagnostic imaging were classified using the Neiman Imaging Types of Service (NITOS) coding system by both modality and body region. Utilization rates per 1000 beneficiaries were calculated for families of services. RESULTS: Among all diagnostic imaging modalities, growth was greatest for MRI (+312%) and CT (+151%) and was lower for ultrasound, nuclear medicine, and radiography and fluoroscopy (range, +1% to +31%). Among body regions, service growth was greatest for brain (+126%) and spine (+74%) imaging; showed milder growth (range, +18% to +67%) for imaging of the head and neck, breast, abdomen and pelvis, and extremity; and showed slight declines (range, -2% to -7%) for cardiac and chest imaging overall. The following specific imaging service families showed massive (> +100%) growth: cardiac CT, cardiac MRI, and breast MRI. CONCLUSION: NITOS categorization permits identification of temporal shifts in noninvasive diagnostic imaging by specific modality- and region-focused families, providing a granular understanding and reproducible analysis of global changes in imaging overall. Service family-level perspectives may help inform ongoing policy efforts to optimize imaging utilization and appropriateness.

Academic Radiologist Subspecialty Identification Using a Novel Claims-Based Classification System.

OBJECTIVE: The objective of the present study is to assess the feasibility of a novel claims-based classification system for payer identification of academic radiologist subspecialties. MATERIALS AND METHODS: Using a categorization scheme based on the Neiman Imaging Types of Service (NITOS) system, we mapped the Medicare Part B services billed by all radiologists from 2012 to 2014, assigning them to the following subspecialty categories: abdominal imaging, breast imaging, cardiothoracic imaging, musculoskeletal imaging, nuclear medicine, interventional radiology, and neuroradiology. The percentage of subspecialty work relative value units (RVUs) to total billed work RVUs was calculated for each radiologist nationwide. For radiologists at the top 20 academic departments funded by the National Institutes of Health, those percentages were compared with subspecialties designated on faculty websites. NITOS-based subspecialty assignments were also compared with the only radiologist subspecialty classifications currently recognized by Medicare (i.e., nuclear medicine and interventional radiology). RESULTS: Of 1012 academic radiologists studied, the median percentage of Medicare-billed NITOS-based subspecialty work RVUs matching the subspecialty designated on radiologists' own websites ranged from 71.3% (for nuclear medicine) to 98.9% (for neuroradiology). A NITOS-based work RVU threshold of 50% correctly classified 89.8% of radiologists (5.9% were not mapped to any subspecialty; subspecialty error rate, 4.2%). In contrast, existing Medicare provider codes identified only 46.7% of nuclear medicine physicians and 39.4% of interventional radiologists. CONCLUSION: Using a framework based on a recently established imaging health services research tool that maps service codes based on imaging modality and body region, Medicare claims data can be used to consistently identify academic radiologists by subspecialty in a manner not possible with the use of existing Medicare physician specialty identifiers. This method may facilitate more appropriate performance metrics for subspecialty academic physicians under emerging value-based payment models.

Radiologist Point-of-Care Clinical Decision Support and Adherence to Guidelines for Incidental Lung Nodules.

PURPOSE: To evaluate the effect of a workstation-integrated, point-of-care, clinical decision support (CDS) tool on radiologist adherence to radiology department guidelines for follow-up of incidental pulmonary nodules detected on abdominal CT. METHODS: The CDS tool was developed to facilitate adherence to department guidelines for managing pulmonary nodules seen on abdominal CT. In October 2012, the tool was deployed within the radiology department of an academic medical center and could be used for a given abdominal CT at the discretion of the interpreting radiologist. We retrospectively identified consecutive patients who underwent abdominal CT (in the period from January 2012 to April 2013), had no comparison CT scans available, and were reported to have a solid, noncalcified, pulmonary nodule. Concordance between radiologist follow-up recommendation and department guidelines was compared among three groups: patients scanned before implementation of the CDS tool; and patients scanned after implementation, with versus without use of the tool. RESULTS: A total of 409 patients were identified, including 268 for the control group. Overall, guideline concordance was higher after CDS tool implementation (92 of 141 [65%] versus 133 of 268 [50%], P = .003). This finding was driven by the subset of post-CDS implementation cases in which the CDS tool was used (57 of 141 [40%]). In these cases, guideline concordance was significantly higher (54 of 57 [95%]), compared with post-implementation cases in which CDS was not used (38 of 84 [45%], P < .001), and to a control group of patients from before implementation (133 of 268 [50%]; P < .001). CONCLUSIONS: A point-of-care CDS tool was associated with improved adherence to guidelines for follow-up of incidental pulmonary nodules.

Regional variation in Medicare payments for medical imaging: radiologists versus nonradiologists.

OBJECTIVE: The purpose of this article was to study regional variation in Medicare Physician Fee Schedule (MPFS) payments for medical imaging to radiologists compared with nonradiologists. MATERIALS AND METHODS: Using a 5% random sample of all Medicare enrollees, which covered approximately 2.5 million Part B beneficiaries in 2011, total professional-only, technical-only, and global MPFS spending was calculated on a state-by-state and United States Census Bureau regional basis for all Medicare Berenson-Eggers Type of Service-defined medical imaging services. Payments to radiologists versus nonradiologists were identified and variation was analyzed. RESULTS: Nationally, mean MPFS medical imaging spending per Medicare beneficiary was $207.17 ($95.71 [46.2%] to radiologists vs $111.46 [53.8%] to nonradiologists). Of professional-only (typically interpretation) payments, 20.6% went to nonradiologists. Of technical-only (typically owned equipment) payments, 84.9% went to nonradiologists. Of global (both professional and technical) payments, 70.1% went to nonradiologists. The percentage of MPFS medical imaging spending on nonradiologists ranged from 32% (Minnesota) to 69.5% (South Carolina). The percentage of MPFS payments for medical imaging to nonradiologists exceeded those to radiologists in 58.8% of states. The relative percentage of MPFS payments to nonradiologists was highest in the South (58.5%) and lowest in the Northeast (48.0%). CONCLUSION: Nationally, 53.8% of MPFS payments for medical imaging services are made to nonradiologists, who claim a majority of MPFS payments in most states dominated by noninterpretive payments. This majority spending on nonradiologists may have implications in bundled and capitated payment models for radiology services. Medical imaging payment policy initiatives must consider the roles of all provider groups and associated regional variation.

The radiology job market: analysis of the ACR jobs board.

PURPOSE: The aim of this study was to assess the status of the radiology job market as represented by the ACR Jobs Board from October 2010 to June 2013. METHODS: With the assistance of the ACR, data from the ACR Jobs Board from October 2010 through June 2013, including the numbers of monthly new job seekers, new job postings, and job posting clicks, were gathered and used to calculate a monthly competitive index, defined as the ratio of new job seekers to new job postings. RESULTS: During the study period, the mean number of new job seekers was 168 per month, which was significantly greater than the 84 average new job postings for any given month (P = .0002). There was no significant difference between 2011 and 2012 with regard to the number of new job seekers or job postings. Over the time period assessed, more new job seekers registered in October and November 2010, August to November 2011, and October and November 2012. These periods were also associated with the highest competitive index values. There were less job seekers in the winter and spring of 2011, 2012, and 2013, periods associated with lower competitive index values. ACR Jobs Board activity, measured by job posting clicks, was significantly higher in 2012 than in 2011 (P < .004). CONCLUSIONS: On the basis of the ACR Jobs Board, there were consistently more new job seekers than job postings throughout the study period, and fall is the period in the year most associated with the highest competitive index for radiologist employment.

Credentialing based on surgical volume, physician workforce challenges, and patient access.

Advances within the medical profession have resulted in an increase in available medical therapeutic options and minimally invasive surgical techniques for common gynecologic conditions. In many circumstances, this has led to a reduction in surgical volume for many common conditions in benign gynecology. There is also some evidence that a threshold number of cases may exist, below which surgical competence may be affected. Although the practice of medicine continues to evolve, there is broad recognition of a projected workforce shortage of physicians. If credentialing or privileging bodies establish criteria based solely on the number of procedures performed by an individual physician, patient access may be greatly affected. From a public health perspective, these issues cannot be considered in isolation. Thoughtful analysis of existing data and recognition of patient access issues should be carefully weighed before any dramatic changes in hospital privileging or hiring practices. Consideration for ongoing maintenance of credentialing should be carefully balanced and strategies for ongoing assurance of competency may require creative alternatives to simple numerical documentation. Differential approaches to regions with different densities of physicians may also be necessary.

Sustainable growth rate 2013: time for definitive intervention.

Federal healthcare spending has been a subject of intense concern as the US Congress continues to search for ways to reduce the budget deficit. The Congressional Budget Office (CBO) estimated that, even though it is growing more slowly than previously projected, federal spending on Medicare, Medicaid and the State Children's Health Insurance Program (SCHIP) will reach nearly $900 billion in 2013. In 2011 the Medicare program paid $68 billion for physicians and other health professional services, 12% of total Medicare spending. Since 2002 the sustainable growth rate (SGR) correction has called for reductions to physician reimbursements; however, Congress has typically staved off these reductions, although the situation remains precarious for physicians who accept Medicare. The fiscal cliff agreement that came into focus at the end of 2012 averted a 26.5% reduction to physician reimbursements related to the SGR correction. Nonetheless, the threat of these devastating cuts continues to loom. The Administration, Congress and others have devised many options to fix this unsustainable situation. This review explores the historical development of the SGR, touches on elements of the formula itself and outlines current proposals for fixing the SGR problem. A recent CBO estimate reduces the potential cost of a 10-year fix of SGR system to $138 billion. This has provided new hope for resolution of this long-standing issue.