Changes for CMS Imaging Reimbursement: 6 Things for Orthopedic and Spine Providers to Know

Written by Laura Dyrda | July 20, 2011 | Print  | Email
If your practice bills Medicare for MRI or CT services, are you prepared for MIPPA? On July 15, 2008, the Centers for Medicare & Medicaid Services (CMS) issued the Medicare Improvements for Patients and Providers Act (MIPPA). Effective Jan. 1, 2012, all non-hospital providers of advanced diagnostic imaging services (ADIS) including CT and MRI examinations must be certified by one of three credentialing agencies in order to receive Medicare payment for technical fees under Part B of the Medicare Physician Fee. MIPPA eliminates any grace period so the entire certification process must be completed by the Jan. 1, 2012 deadline in order for orthopedic groups or musculoskeletal imaging centers to receive payment. The accreditation requirements are stringent and a minimum of 2-6 months is required to complete the accreditation process.

"Many orthopedic groups are not aware of the potential impact of MIPPA on their practice" says Douglas K. Smith, MD, President of Musculoskeletal Imaging Consultants LLC. "If an orthopedic group owns or operates an uncertified MRI, the first time the group may become aware of MIPPA is when the group's Medicare claims are denied and the group is prevented from billing Medicare for months while it obtains MIPPA compliance. Medicare may even deny payment to orthopedic groups with a currently certified scanner if the group does not address new MIPPA quality assurance requirements. MIPPA may adversely affect orthopedic groups even if they don't own a scanner. They may suddenly discover that their favorite imaging center suddenly stops accepting Medicare patients after 1/1/12 because the scanner or center has failed to meet the 1/1/12 MIPPA certification deadline".

Dr. Smith discusses six points on the changes and how providers can prepare for them.

1. Practices with in-office MRI and imaging centers with MRI or CT need accreditation to receive Medicare payment after Jan. 1.
Prior to MIPAA/CMS, there was no Medicare requirement for scanner certification or requirement for quality assurance processes and procedures. However, this is all about to change. Effective Jan. 1, 2012, orthopedic groups with in-office MRI or owners of imaging centers must certify their MRI or CT by one of three credentialing entities in order to receive payment from Medicare.

The American College of Radiology (ACR), Intersocietal Accreditation Commission (IAC) and The Joint Commission (TJC) are the only CMS approved accreditation entities.. Ambulatory surgical centers typically bill Medicare under the Hospital Outpatient Prospective Payment System (HOPPS) rather than the Physician Fee Schedule and therefore are not affected by the MIPPA mandates.   

"MIPPA will ultimately improve the quality of imaging provided to all patients by requiring performance and safety standards for imaging devices and all personnel that use them to scan Medicare patients," says Dr. Smith. "At first these performance standards must only be met for Medicare patients but it likely that MIPPA certification standards will also be required by insurance carriers for all scanners."

2. CMS requires providers to complete three tasks.
CMS requires providers to: obtain and maintain certification of applicable imaging devices; provide primary verification of training and licensure of all medical staff and radiologists and a comprehensive quality assurance program; provide documentation of policies and procedures related to safety of patients and health workers.

"Orthopedic practices may not be experienced with the scientific aspects of diagnostic imaging or have the experience required to establish and maintain radiology quality programs," says Dr. Smith. "Orthopedic practices may find it advisable to seek professional radiologic consultation before heading into the credentialing process and preparation for MIPPA."

Hiring an orthopedic teleradiology company such as Musculoskeletal Imaging Consultants to assist your practice with credentialing may be beneficial. Imaging protocols can be optimized to meet the specific requirements of the group during the scanner certification.

3. Just because your scanner is currently certified doesn't mean you'll meet 2012 MIPPA requirements.
These additional requirements include: primary source verification of personnel qualifications; policies on patient record retention and retrieval; policies and posted notices regarding contact information for consumer complaint; and policies on staff and patient safety. "It's time for everyone to perform a MIPPA inventory because if you if you don’t qualify, you won’t get paid by Medicare after January 1, 2012," Says Dr. Smith.

MIPPA calls for unannounced visits from CMS or the accrediting agency to assure compliance and requires the accrediting agency to report all accreditation information to CMS. Finally any false or misleading information provided to an accreditation body to achieve accreditation can be used to initiate a federal fraud investigation. "Another good reason to carefully document MIPPA compliance is that if you bill Medicare and a surprise auditor shows up at your scanner, you could go to jail," says Dr. Smith.


Another change is the requirement of a designated "supervising physician," The supervising physician has advanced training and experience in diagnostic imaging including continuing medical education. "Usually this person would be a radiologist, although it could be a clinician with considerable formal imaging training and documented experience," says Dr. Smith. "This is an important aspect of the new requirements perhaps some ADIS providers don't fully understand the implications of executing this role."

4. No more grace period—If you are "in-process" on January 1, 2012, you will not receive payment for any services provided until the date when the certification is complete—no exceptions. CMS makes it clear that it will not pay any provider for covered services after Jan. 1, 2012 unless they are certified at the time the service was provided. The accreditation process can take months and during that time, the provider cannot be paid for Medicare patients until the certification process is complete. The most widely used accreditation entity, the American Board of Radiology (ABR), requires the submission of sample diagnostic images for quality assurance assessment.

"Time and money can be saved by involving a radiologist consultant in the process of scanner quality assurance and selecting images for submission to the ACR," says Dr. Smith. Failure to recognize and correct a scanner artifact before the images are submitted to the ABR can cause your application to be rejected, necessitating costly delays involved with remediation and reapplication. If an experienced teleradiology company is engaged, the scanner protocols can be specifically adjusted to the needs of the orthopedic practice and quality assurance program can be established during the application process.

5. Inspectors may make surprise visits to your facility. Having the appropriate technology is only part of the accreditation battle. The provider must also have policies and procedures in place that prove the provider has a focus on quality. Prepare for this portion of the process by making sure all medical professionals have their primary credentials reviewed and primary source verification. "Everyone has to file their active credentials, so you might want to have an inventory of personnel requirements," says Dr. Smith.

CMS may now send an inspector to the facility on a random, unannounced visit, and these inspectors will want to see all the appropriate forms. Providers need to conduct a rigorous audit to make sure things are in place in case an inspector shows up. "One of the risks of non-compliance is that you won't get paid," says Dr. Smith. "If you say you are compliant and they find you are not, you are committing federal fraud."

6. Providers that make these changes will have the competitive edge in the future.
Even though CMS is the only payor currently requiring stricter compliance from providers for imaging reimbursement, facilities that achieve the higher level of certification will have the advantage over others in the future. Accredited providers will be prepared when commercial payors increase imaging standards to meet Medicare's baseline. "I suspect that other payors will ask for accreditation before making payments in the future," he says. "At the front end, this will be hard for folks who aren't prepared to meet it or don't invest in the process."

One clear advantage comes from the marketing standpoint because facilities that have the accreditation will be able to attract patients as a certified center. "If you're certified, you can proudly display the certification logo in your marketing materials and at your facility," says Dr. Smith. "Marketing packages are available from the ACR that will convey to your patients and medical colleagues that you are ‘best of class' in your community."

Musculoskeletal Imaging Consultants can provide guidance to imaging centers or practices that are going through the accreditation process. Learn more about Musculoskeletal Imaging Consultants.


Related Articles on Orthopedic Imaging:

Trends and Insights Into Orthopedic Teleradiology: Q&A With Radiologist Dr. Douglas Smith

iPad-Based Radiology Interface for Orthopedic and Spine Surgeons: Virtual Viewbox From Musculoskeletal Imaging Consultants

AAOS: New Imaging Technology Could Benefit Spinal Navigation


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