A “treating physician” is a physician, as defined in §1861(r) of the Social Security Act (the Act), who furnishes a consultation or treats a beneficiary for a specific medical problem, and who uses the results of a diagnostic test in the management of the beneficiary’s specific medical problem. A radiologist performing a therapeutic interventional procedure is considered a treating physician. A radiologist performing a diagnostic interventional or diagnostic procedure is not considered a treating physician. (Medicare Manual transmittal)
On April 1, 2020, the ACR sent a letter to the director of practitioner services at CMS asking for removal of these restrictions on radiologists. What is the College’s strategic objective when advocating for changes to the treating physician rules?
This is a timely question — with the answer informed by several evolving events initially unrelated to COVID-19. The primary impetus emanated from changes in reporting criteria for evaluation and management (E&M) services — set to be implemented in January of 2021. As a reminder, the E&M CPT® codes have been revised and revalued, with significant upward adjustment of relative value units. In a budget neutral payment system, the increase in E&M reimbursement results in decreased payments for all other services (most pertinently imaging services). Additionally, under the new, revised E&M coding structure, radiologists might meet the CPT criteria for making medical decisions about radiographic care — most notably in managing incidental findings, an area of imaging in which we are truly the experts. Meeting the CPT criteria is bittersweet as no payment would be allowed in accordance with the Act’s restrictions. Perhaps this gap in payment is at least partly responsible for the suboptimal follow-up rate of radiographically significant incidental findings reported in the literature ranging from 29–77%.1,2,3 In general, when there is a care gap, there is often a payment gap — as the old adage goes: you get what you pay for.
Medicare has singled out diagnostic radiologists as incapable of managing patients, but allows non-physician providers — with less training on imaging appropriateness — the regulatory freedom to manage patients and order imaging. Given this interplay, the Commission on Economics asked the question, “Should we advocate for changing these rules, and improve appropriate follow-up on radiographically significant incidental findings?” Creating a care pathway in which primary care clinicians and radiologists are jointly accountable for coordinating and ensuring correct management of these findings could help close this gap. After all, accountability and patient attribution are key components in improving overall population health and prescribing the lion’s share of distributed shared savings inside alternative payment models.
Why do the treating physician rules exist? Rather ironically, it is in part to protect against radiologist’s self-referral abuse. Unless we address this potential abuse, we are unlikely to move the needle on radiologists taking ownership of more of the imaging process from start to finish. Tempering the potential abuse is easier now with value-based payment paradigms because radiologists can create value-based measures of appropriateness designed to minimize inappropriate image follow-up recommendations and decrease variability of imaging care. One initiative led by the ACR is already underway through its Commission on Quality and Safety via the Gordon and Betty Moore Foundation’s Diagnostic Excellence Initiative grant, which focuses on creating measures related to incidental findings. Measure development for use as a value-based payment is a long and arduous task of choosing measures amenable to data collection, supported by science, and acceptable to the broader house of medicine — as well as payors. One initiative based on one grant will not be enough, but we have to start somewhere.
Imagine a world in which radiologists recommend the right follow-up test at the right time, and the radiologist is confident the follow-up will be completed correctly and expediently. The ACR’s deep expertise across multiple commissions, combined with the common goal of advocating for patients and members, can close this care gap.
Why do the treating physician rules exist? Rather ironically, it is in part to protect against radiologist’s self-referral abuse. Unless we address this potential abuse, we are unlikely to move the needle on radiologists taking ownership of more of the imaging process from start to finish.