2/28/2011. MIPPA overview and CMS requirements. CT accreditation. Today s agenda. About MIPPA. Computed Tomography

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1 Today s agenda Computed Tomography Presented by: Dina Hernandez, BSRT, RT (R), CT, QM Krista Bush, RT, MBA Leonard Lucey, JD ACR Quality & Safety MIPPA overview and CMS requirements CT accreditation How to prepare for accreditation Getting ready to submit your materials Q & A Feb. 24, MIPPA overview and CMS requirements About MIPPA The Medicare Improvements for Patients and Providers Act (MIPPA) passed in July 2008 Providers of advanced diagnostic imaging services (ADIS) that bill under Part B of the Medicare Physician Fee Schedule must be accredited by Jan. 1, 2012 to receive payment for the technical component of these service Beginning Jan. 1, 2012, payment will only be made if your facility is fully accredited Facilities that already have accreditation must keep renewals current 3 4 New CMS requirements by deadline even if you are currently accredited Verification of personnel qualifications for supervising physician and non-physician staff With primary source verification Written policy on patient access to information Including patient record retention and retrieval process A policy for consumer complaints Including posted notice about where/how to file a complaint with the provider s accrediting organization Policies for staff and patient safety CT accreditation 5 6 1

2 CT overview The CT accreditation program involves the acquisition of clinical and phantom images, dose measurements and the submission of scanning protocols Every unit that performs diagnostic head/neck, chest, cardiac or abdomen examinations must go through testing for the site to be accredited. Every unit must apply for all modules performed on that unit for a facility to be accredited How to prepare for accreditation 7 8 How to prepare for accreditation Go to acr.org and read the CT program requirements Existing facility apply using ACRedit (acredit.acr.org) Use mailed instructions to activate the account, login with an already active address and password; or call the ACR. New facility go to acr.org and register in the online application

3 CT now in ACRedit! Advantages of using ACRedit Eliminates paperwork Save work and finish later User friendly Guides you through process Automatic notifications Automatically calculates fees and deducts discounts Online application Application includes: Facility information Modality information CMS information Medicare ID number National provider identifier Payment options Modular format CT program is modular: Head/neck module Chest module Abdomen module Cardiac module (new physician requirements) Provides specialty sites (urology, neurology etc.) greater flexibility to achieve ACR accreditation Clinical images Clinical examinations will be of the head/neck, chest, cardiac and abdomen regions Three to four examinations and a copy of the facility s protocol for that examination must be submitted from each unit. The exact number of examinations depends on the number of modules for which the unit is used If the unit is a specialty unit, and does not perform examinations from all four modules, at least three exams are still required from that unit Facilities may not submit images performed on models or volunteers. All clinical images must be from actual patients

4 Application selections Adult and pediatric, adult only or pediatric only Sites select the modules and exams Sites select to submit the clinical exams on film or CD Note: Phantom images must be submitted on CD Exam selections Adult Examinations Head/neck Chest Abdomen Cardiac Head (such as for Chest (such as for Abdomen (such as for Calcium scoring (No headaches and to exclude evaluation of known or detection of possible liver more than one exam) neoplasm) suspected lung cancer or metastases or lymphoma) CTA (required)* Temporal bones* cough) Known cirrhosis (R/O hepatoma)* Pulmonary vein Cervical spine for known or Suspected pulmonary Evaluation of known mapping Suspected fracture* Embolus* renal mass (including ROI Cardiac function and High-resolution CT of chest (HRCT) for evaluation of diffuse lung disease* Assessment of possible aortic dissection* measurements)* Evaluation of a patient with suspected pancreatic Carcinoma* morphology, such as, for tumor, congenital heart disease, aortic valve or cardiomyopathy * specialty exam Exam selections Pediatric Examinations Head/neck Chest Abdomen Cardiac Pediatric head CT (such Pediatric chest (such as Pediatric abdomen Pediatric cardiac such as for headaches, for detection of (such as for blunt as for congenital Exam selections Number of modules on application One module Number of examinations per module Three examinations are required, at least one of which must be a specialty examination. If adult and pediatric, at least one of the examinations must be a pediatric examination. Total exams per unit Three seizures, or suspected mass metastatic disease, trauma, infection, or cough trauma, acute abdominal pain, or disease Two modules Select one specialty examination from either module and one routine examination from each module. If adult and pediatric, at least one of the examinations must be a pediatric examination. Three Pediatric sinus for infection Pediatric cervical spine* Pediatric high-resolution CT of chest (HRCT) for evaluation of diffuse lung infection) Pediatric CT for adrenal/renal mass* Three modules Select one specialty examination from one module, and select one examination from each of the other two modules. If adult and pediatric, at least one of the examinations must be a pediatric examination. Three Pediatric temporal Bones* disease* Four modules The CTA examination from the cardiac module is required in addition to, one examination from each of the other three modules. If adult and pediatric, at least one of the examinations must be a pediatric examination. Four * specialty exam Submission All clinical and phantom testing instructions are available on the website in the Computed Tomograhy section Testing and QC forms Once an application is accepted, an online testing packet is activated in the ACRedit database and barcode labels are mailed All sites need to fill out and submit the data forms found in My testing packet in the ACRedit database Generic data forms are available on the ACR website under Testing and QC forms The generic forms can be used to document information while scanning and then used to enter the data in the online testing packet Clinical image evaluation Based on the Clinical Image Quality Guide found in Testing and QC forms under the Computed Tomography Section of the website The clinical images are evaluated for: Technique parameters Anatomic coverage and display Artifacts Exam identification and missing information Exam protocol

5 ACR phantom An ACR phantom (Gammex 464) must be used to accredit all units at a facility A complete set of phantom images along with dose measurements taken with the appropriate dose phantoms from every CT unit at the facility must be submitted The order form for the Gammex 464 phantom is available on the acr.org website ACR phantom 20 cm HEAD 4 3 High Uniformity Contrast & Resolution Noise 2 Low Contrast Resolution FOOT 1 Alignment & CT Accuracy 4 cm Phantom scanning Phantom is scanned with specific exam protocols and that are dependent upon the sites application: All sites will scan the phantom with an adult abdomen protocol All sites who apply for adult and pediatric accreditation will scan the phantom with an adult and pediatric abdomen protocol Dependent upon the clinical exam choices in the application, sites may also scan the phantom with an adult head and pediatric head protocol Sites can review their submitted data report in ACRedit to see what protocols will be required for ACR phantom testing Phantom evaluation Evaluating the phantom images: CT number calibration Low contrast criteria (contrast to noise ratio) Uniformity Artifacts CT number accuracy CT number accuracy Polyethylene HU between -107 and -84 Water HU between -7 and +7 Acrylic HU between +110 and +135 Bone HU between 850 and 970 Air HU between and -970 Evaluate adult abdomen protocol CT number accuracy Water HU between -7 and +7 Evaluate for all other protocols that are submitted for the phantom testing

6 Contrast-to-noise ratio Contrast to noise ratio Low contrast criteria (contrast-to-noise ratio) Signal in ROI inside 25 mm rod (A) Mean signal in the ROI outside the 25 mm rod (B) Standard deviation (SD) from ROI outside 25 mm rod CNR= A-B /SD CNR must be greater than 1.0 for adult head, pediatric head and adult abdomen protocol CNR must be greater than 0.5 for the pediatric abdomen protocol Uniformity Uniformity Measure and record the mean CT numbers for the center and four edge ROI values All CT numbers for all four edge ROIs must be 0 ± 5 of the center ROI mean signal measurement Dosimetry Protocols used for dosimetry are the same protocols used on ACR phantom scanning Head CTDI phantom: 16 cm diameter, 15 cm length Used for the adult and pediatric head scans and the pediatric abdomen scan Body CTDI phantom: 32 cm diameter, 15 cm length Used for the adult abdomen scan Dose calculation Excel spreadsheets are available at: acr.org/accreditation/computed/qc_forms.aspx Dosimetry Examinations Pass/Fail Criteria Reference Levels CTDIvol (mgy) CTDIvol (mgy) Adult head Adult abdomen Pediatric abdomen Pediatric head To be determined To be determined

7 An important note To be accredited with the ACR, a CT unit must pass both the clinical and phantom image quality tests. The phantom (and the unit) will fail ACR accreditation if the dose from the CT unit exceeds the pass/fail criteria. The facility must repeat the entire phantom portion of the accreditation testing, and pass, for the unit to be granted accreditation. Getting ready to submit your materials Timeline Sites have 45 days to complete and submit testing materials after applying Extensions are considered on a caseby-case basis Let us know if you need more time Preparing clinical materials film If the clinical exams are submitted on film, all appropriate window widths and levels must be submitted Scout images with and without reference lines must be submitted Label all of the films in the appropriate order with the barcode labels Preparing clinical materials CD If the clinical exams are submitted on CD, the CD must contain an embedded DICOM viewer that displays all of the required scan and display parameters listed in the testing instructions Include scout views with and without reference lines Burn all exams onto one CD and then create a copy Both copies must be sent for accreditation review Label the envelope, sleeve or plastic case of each CD with the appropriate CD 1 or CD 2 barcode label Preparing the phantom CD Burn all of the ACR phantom and dosimetry images for each required protocol to one CD and then create an exact copy The phantom CD may or may not contain an embedded DICOM viewer Label each CD envelope, sleeve or plastic case with CD 1 and CD 2 phantom barcode labels

8 Submitting materials Submit the online testing packet in ACRedit Print the forms for submission Place the barcode labels on the appropriate forms Submitting materials Submission packet should include Two copies of clinical CD (or one set of filmed images for each exam) Clinical Data Forms for each clinical exam A copy of the facility s scanning protocol for each clinical exam Two copies of the phantom CD Phantom Scanning Data Form including all required dose spreadsheets Annual system performance evaluation Final reports Final reports are generated after complete reviews by the ACR radiologist and physicist reviewers Final reports links are ed to the modality supervising physician and facility administrator All images are mailed back to the site When accreditation is achieved, sites will receive an accreditation certificate, decal and marketing packet CT accreditation fees Initial cycle and renewal: $2400 for first unit, up to three modules $2500 for first unit for all four modules $2300 each additional unit at one site location, up to three modules $2400 for each additional unit for all four modules Q. Is my hospital required to be accredited under the new MIPPA legislation? A. No, only providers of advanced diagnostic imaging services (ADIS) that bill under Part B of the Medicare Physician Fee Schedule must be accredited Q. Do all units in the facility need to be evaluated? A. Yes, in order to be accredited, a facility must have all units evaluated and approved. Clinical and phantom images must be submitted for every unit

9 Q. Do we have to submit images from a set timeframe? A. All phantom and clinical images must be from the same 60-day period and within 30 days before or after phantom images. Q. How much time do I have to return the testing package to the ACR? A. Testing materials are due 45 calendar days from the date testing materials were mailed to your facility. This 45-day period ensures your facility can get through the accreditation process in a timely manner. Please let us know if you need extra time. Q. What options do we have if we fail the initial test cycle? A. Facilities that do not meet the initial evaluation criteria have the choice to appeal or repeat. If they chose to repeat, facility will only be required to resubmit the procedure that was deficient. Facilities that re-apply after deficiency are required to submit their online request for repeat application, along with the fee of $800 per scanner for clinical or phantom or $1600 per scanner if repeating both, within 15 days of their report. Q. Do facilities have to undergo a site survey as part of the accreditation process? A. ACR does not require an on-site pre-accreditation survey. For accredited facilities, ACR and/or CMS will conduct unannounced site visits within the three-year accreditation period to validate maintenance of accreditation criteria Q. What are the requirements for adult vs. pediatric scanning? A. For sites that perform only adult CT scanning, clinical images required for submission will be both basic and specialized examinations in the modules routinely performed on that unit. For sites that do occasional pediatric scanning ( 15 years of age) in addition to adult work, an additional exam performed on a child will also have to be selected for submission. Sites that perform only pediatric examinations (only patients 15 years of age) will have to submit basic and specialized exams tailored to the pediatric population. Q. Do you need a Medical Physicist Survey for each scanner? A. Yes, a Medical Physicist Survey must be done yearly for each scanner being accredited. This report is be submitted with the accreditation testing materials Why choose ACR for accreditation? Developed by radiologists Accreditation generally within 90 days of image submission No pre-accreditation on-site survey Save 10% on three or more modalities (excluding mammography) Multi-site, multi-modality pricing Renewal is faster and easier - Average renewal pass rate 85% Custom marketing toolkit Based on ACR Practice Guidelines and Technical Standards Focus on quality and safe imaging Peer-reviewed assessment of clinical and phantom images Continuous practice improvement process with key performance metrics Dedicated account team of technologists guide you every step of the process ACR nationally recognized accreditation programs

10 Q & A discussion Accreditation hotline: CT: Dina Hernandez dhernandez@acr.org 55 10