Excellence in Diagnostic Imaging Utilization Act of 2013 - Amends title XVIII (Medicare) of the Social Security Act (SSA) to establish appropriateness requirements for certain outpatient advanced diagnostic imaging services for which payment is made under the technical or professional component of the physicians' fee schedule or the prospective payment system for hospital outpatient department services.
Defines "applicable advanced diagnostic imaging services" as those for which defined appropriate use criteria (and related guidelines) have been: (1) developed or endorsed by national professional medical specialty societies, and (2) selected by the Secretary of Health and Human Services (HHS) in consultation with such societies and other stakeholders.
Directs the Secretary to: (1) qualify imaging appropriateness registries developed and maintained by such societies, (2) publish a list of qualified suppliers of approved electronic clinical decision support tools, and (3) establish standards for the approval of such tools.
Directs the Secretary, for the purpose of making incentive payments for quality reporting, to treat an eligible advanced diagnostic imaging services professional as satisfactorily submitting data on quality measures if, instead of reporting measures under the established quality reporting system, the professional demonstrates compliance with the registry submission or consultation requirements of this Act for at least 90% of claims for applicable advanced diagnostic imaging services submitted in the year. Limits this treatment to eligible professionals who furnish the technical or professional component of applicable advanced diagnostic imaging services or who order such services.
[Congressional Bills 113th Congress]
[From the U.S. Government Publishing Office]
[H.R. 3705 Introduced in House (IH)]
113th CONGRESS
1st Session
H. R. 3705
To amend title XVIII of the Social Security Act to establish
appropriateness requirements for certain advanced diagnostic imaging
services, and for other purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
December 11, 2013
Mr. Paulsen (for himself and Mr. Matheson) introduced the following
bill; which was referred to the Committee on Energy and Commerce, and
in addition to the Committee on Ways and Means, for a period to be
subsequently determined by the Speaker, in each case for consideration
of such provisions as fall within the jurisdiction of the committee
concerned
_______________________________________________________________________
A BILL
To amend title XVIII of the Social Security Act to establish
appropriateness requirements for certain advanced diagnostic imaging
services, and for other purposes.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Excellence in Diagnostic Imaging
Utilization Act of 2013''.
SEC. 2. APPROPRIATENESS REQUIREMENTS FOR CERTAIN ADVANCED DIAGNOSTIC
IMAGING SERVICES.
(a) In General.--Section 1834 of the Social Security Act (42 U.S.C.
1395m) is amended by adding at the end the following new subsection:
``(p) Appropriateness Requirements for Certain Advanced Diagnostic
Imaging Services.--
``(1) In general.--
``(A) In general.--Beginning with January 1, 2015,
with respect to applicable advanced diagnostic imaging
services furnished in an outpatient setting and for
which payment is made under--
``(i) the technical or professional
component of the fee schedule established under
section 1848(b); or
``(ii) the prospective payment system for
hospital outpatient department services under
section 1833(t),
payment for such services may only be made if the
requirements of this subsection are met.
``(B) Applicable advanced diagnostic imaging
services.--For purposes of this subsection, the term
`applicable advanced diagnostic imaging services' means
advanced diagnostic imaging services (as defined in
subsection (e)(1)(B)) for which defined appropriate use
criteria (and related guidelines) have been--
``(i) developed or endorsed by national
professional medical specialty societies; and
``(ii) selected by the Secretary for
purposes of this subsection in consultation
with national professional medical specialty
societies and other stakeholders.
``(C) Construction in instances of multiple
applicable appropriate use criteria.--Nothing in this
subsection shall be construed as preventing the
Secretary, in the case that there are multiple
appropriate use criteria (and related guidelines) that
are applicable to a particular advanced diagnostic
imaging service (or a specific set of clinical
indications), from selecting more than one criterion
(or more than one guideline) under subparagraph
(B)(ii)(II).
``(D) Periodic revision.--The Secretary may
periodically revise the list of applicable advanced
diagnostic imaging services under this paragraph.
``(2) Development and maintenance of imaging
appropriateness registries by medical specialty societies.--
``(A) In general.--Not later than April 1, 2014,
the Secretary shall qualify registries that are
developed and maintained by national professional
medical specialty societies.
``(B) Requirements.--Registries qualified under
subparagraph (A) shall meet the following requirements:
``(i) The registry shall document--
``(I) the use of an approved
electronic clinical decision support
tool (as described in paragraph (3)) in
connection with the ordering and
performance of an applicable advanced
diagnostic imaging service;
``(II) whether orders for
applicable advanced diagnostic imaging
services were consistent with related
appropriate use criteria (including an
appropriateness score where available
from the approved electronic clinical
decision support tool);
``(III) the clinical indication for
the applicable advanced diagnostic
imaging services ordered; and
``(IV) in situations where an order
for an applicable advanced diagnostic
imaging service is not consistent with
the related appropriate use criteria,
the rationale of the ordering or
furnishing supplier or provider (as the
case may be) for such inconsistency.
``(ii) The registry shall be structured to
allow access to data for future research,
provide a centralized analysis of the data
submitted, including the impact on utilization
changes for applicable advanced diagnostic
services, and provide connections with existing
medical society registries.
``(iii) The registry shall generate reports
on at least a quarterly basis providing
feedback to suppliers and providers that order
and furnish applicable advanced diagnostic
imaging services on the ordering activity of
the supplier or provider and related
appropriate use criteria metrics.
``(C) Multiple qualified registries.--In the case
where more than one registry is developed under this
paragraph, the Secretary shall ensure that each
registry receives standardized data such that the data
may be combined and compared across registries.
``(D) Periodic updating.--The Secretary shall
periodically update the list of registries qualified
under this paragraph.
``(3) Listing of qualified suppliers of approved electronic
clinical decision support tools.--
``(A) In general.--Not later than July 1, 2014, the
Secretary shall publish a list of qualified suppliers
of approved electronic clinical decision support tools,
in accordance with the provisions of this paragraph.
``(B) Standards.--
``(i) In general.--The Secretary, in
consultation with the medical specialty
societies described in paragraph (2)(A), shall
establish standards for the approval of
electronic clinical decision support tools
provided by qualified suppliers.
``(ii) Standards.--The standards
established under clause (i) shall include the
ability of such tool to--
``(I) use only standards and
guidelines developed by national
medical specialty societies;
``(II) capture the clinical
indication for the applicable advanced
diagnostic imaging services ordered,
selected from the related appropriate
use criteria;
``(III) accurately deliver to the
ordering clinician appropriate use
criteria (and related guidelines) for
applicable advanced diagnostic imaging
services, regardless of the physician
specialty (if any) from which the
criteria or guidelines originated or to
which the criteria or guidelines are
directed;
``(IV) in the case where there are
multiple standards or guidelines
applicable to a particular service or a
specific set of clinical indications,
indicate the standards or guidelines
that are being applied;
``(V) determine the appropriateness
of orders for such services;
``(VI) submit standardized data to
one or more registries qualified under
paragraph (2) that is sufficient for
such registries to meet their
documentation obligations under that
paragraph;
``(VII) be regularly and timely
updated;
``(VIII) generate a unique
electronic identifier (referred to in
this subsection as a `Clinical Decision
Support Number') that documents the
fact that the clinical decision support
tool was consulted by the ordering
supplier or provider in connection with
the ordering of an applicable advanced
diagnostic imaging service; and
``(IX) perform other functions
determined to be necessary by the
Secretary in consultation with the
medical specialty societies described
in paragraph (2)(A).
``(C) Design.--An approved electronic clinical
decision support tool under this paragraph--
``(i) may use a web-based portal, or be
imbedded into an electronic health record
system or other health information technology
tool; and
``(ii) shall meet the privacy and security
standards under the regulations promulgated
pursuant to the Health Insurance Portability
and Accountability Act of 1996.
``(D) Usage and convenient access requirements.--
The Secretary shall only include in the list published
under this paragraph approved electronic clinical
decision support tools provided by suppliers who--
``(i) attest that they have obtained
permission to incorporate appropriate use
criteria (and related guidelines) developed by
national medical specialty societies; and
``(ii) demonstrate that they can provide
convenient access to such a tool via a secure
web-based portal at no cost to--
``(I) suppliers and providers who
order and furnish applicable advanced
diagnostic imaging services under this
title; and
``(II) the Federal government.
``(E) Periodic updating.--The Secretary shall
periodically update the list of qualified suppliers of
approved electronic clinical decision support tools
that meet the standards established under subparagraph
(B) and the other requirements of this paragraph.
``(4) Consultation requirement.--The Secretary shall
require that, as a condition of participation in the program
under this title, suppliers and providers who order an
applicable advanced diagnostic imaging service shall agree to
consult an approved electronic clinical decision support tool
listed pursuant to paragraph (3) in connection with such order.
``(5) Payment for services contingent upon registry
submission.--
``(A) In general.--With respect to an applicable
advanced diagnostic imaging service, payment for the
technical or professional component of such service
under the fee schedule established under section
1848(b) or under the prospective payment system for
hospital outpatient department services under section
1833(t) may only be made if the documentation
accompanying any such claim for payment demonstrates
that an approved electronic clinical decision support
tool listed pursuant to paragraph (3) was consulted and
the required information was submitted to a registry
qualified under paragraph (2).
``(B) Demonstration of compliance.--Compliance with
the requirements under subparagraph (A) may be
demonstrated by the inclusion of a Clinical Decision
Support Number with the claim for payment.
``(6) Exemptions.--
``(A) Significant hardship exemption.--The
Secretary may, on a case-by-case basis, exempt a
supplier or provider to whom this subsection would
otherwise apply if the Secretary determines, subject to
annual renewal, that compliance with this subsection
would result in a significant hardship, such as in the
case of a supplier or provider who lacks access to an
electronic records system or high-speed Internet
access.
``(B) Emergency services exemption.--Applicable
advanced diagnostic imaging services ordered emergently
as part of an emergency medical evaluation shall not be
subject to the requirements of this subsection.
``(C) Clarification of inapplicability to inpatient
services.--Advanced diagnostic imaging services ordered
for inpatients and for which payment is made under part
A are not subject to the requirements of this
subsection.
``(7) Limitations.--The Secretary may not utilize the
authority provided under this subsection to--
``(A) impose any requirement that a supplier or
provider obtain approval to order an advanced
diagnostic imaging service before performing such
service or any other requirement for prior
authorization with respect to such service; or
``(B) use approved electronic clinical decision
support tools to make claims payment determinations
under this title.
``(8) Rulemaking regarding patient safety.--The Secretary
shall promulgate regulations to address situations in which a
supplier or provider, prior to performing an applicable
advanced diagnostic imaging service for an individual,
reasonably believes that the service ordered, if performed,
would pose a safety risk to the individual and that a different
imaging service is more appropriate under the circumstances.
Such regulations shall define circumstances in which the
supplier or provider may change the order to an imaging service
the supplier or provider determines is more appropriate.''.
(b) Compliance With Appropriateness Registry Treated as
Satisfactory Quality Reporting.--Section 1848(m)(3) of the Social
Security Act (42 U.S.C. 1395w-4(m)(3)) is amended--
(1) by redesignating subparagraph (F) as subparagraph (H);
and
(2) by inserting after subparagraph (E) the following new
subparagraphs:
``(F) Satisfactory reporting measures through
participation in imaging appropriateness registry.--
``(i) In general.--For 2015 and subsequent
years, the Secretary shall treat an eligible
professional described in clause (ii) as
satisfactorily submitting data on quality
measures under subparagraph (A) if, instead of
reporting measures under subsection (k)(2)(C),
the eligible professional provides evidence, in
a form and manner specified by the Secretary,
demonstrating that the registry submission
requirements under section 1833(p)(5) have been
complied with with respect to not less than 90
percent of claims for applicable advanced
diagnostic imaging services (as defined in
section 1833(p)(1)(B)) submitted by the
eligible professional in the year.
``(ii) Eligible professional described.--
For purposes of clause (i), an eligible
professional described in this clause is an
eligible professional who furnishes the
technical or professional component of
applicable advanced diagnostic imaging services
(as so defined).
``(G) Satisfactory reporting measures through
participation in imaging appropriateness registry.--
``(i) In general.--For 2015 and subsequent
years, the Secretary shall treat an eligible
professional described in clause (ii) as
satisfactorily submitting data on quality
measures under subparagraph (A) if, in lieu of
reporting measures under subsection (k)(2)(C),
the eligible professional provides evidence, in
a form and manner specified by the Secretary,
demonstrating that they have complied with the
consultation requirements under section
1833(p)(4) with respect to not less than 90
percent of claims for applicable advanced
diagnostic imaging services (as so defined)
submitted by the eligible professional in the
year.
``(ii) Eligible professional described.--
For purposes of clause (i), an eligible
professional described in this clause is an
eligible professional who orders applicable
advanced diagnostic imaging services (as so
defined).''.
(c) Conforming Amendment.--Section 1833(t)(16) of the Social
Security Act (42 U.S.C. 1395l(t)(16)) is amended by adding at the end
the following new subparagraph:
``(E) Application of appropriateness requirements
for certain advanced diagnostic imaging services.--For
provisions relating to the application of
appropriateness requirements for certain advanced
diagnostic imaging services, see section 1834(p).''.
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Introduced in House
Introduced in House
Referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Subcommittee on Health.
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