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Radiology and Nuclear Medicine Changes: CMS Revises the Guidelines

The Centers for Medicare and Medicaid Services recently published an important memo that every hospital should know about: a revision of the interpretive guidelines for radiology and nuclear medicine.

AHC Media will conduct a webinar on these changes to the radiology and nuclear medicine on Thursday, Sept. 10, from 1-3 pm Eastern. Watch for details soon at

In the past several years there has been a focus on ensuring the safety in the use of ionizing radiation. Exposure to ionizing radiation has doubled in the past 20 years. Increasing exposure has been shown to increase cancer risks. CMS also noted studies finding problems with quality control, training of staff, and overutilization. There have been reports of patients receiving radiation overdoses associated with CT scans for evaluation of stroke.

Some of the new changes and issues in the radiology interpretive guidelines include:

  • Radiology services, no matter where they are performed throughout the hospital, must follow approved standards for safety and all staff must be qualified.
  • The hospital must have policies and procedures for radiology safety and to ensure staff are qualified and these must be consistently applied throughout the organization.
  • The P&P must be consistent with accepted professional standards for radiologic services, including the FDA, American College of Radiology, Radiological Society of North America, Alliance for Radiation Safety in Pediatric Imaging (Image Gently), American Society of Radiologic Technologists, the American College of Cardiology, the American College of Neurology, and the American College of Physicians.
  • Radiography, CT, and fluoroscopy utilize ionizing radiation can damage DNA and cause cancer as opposed to MRI or ultrasound. The literature shows risk of cancer from CT is 1:1000.
  • Risks to patient and staff depend on the modality used, length of the procedure or study, size of the patient, device being used, and other factors.
  • Scope of diagnostic radiologic services available must be specified in writing.
  • Radiology services can be provided by hospital staff or through contracted services but the hospital must still make sure all the radiology standards are met.
  • Interpretation of the radiologic study can be remotely via teleradiology as long as practitioner is privileged according to the board and medical staff section.
  • The surveyor may ask the hospital how it meets the needs of its patients.
  • The surveyor will ensure that if the hospital has an emergency department that radiology services support the ED at all times.
  • Principle for ionizing radiation is ALARA (As Low As Reasonably Achievable), which is defined by the EPA.
  • Radiation dosage and radiation doses to patients should always be optimized and exceeding dose limits should prompt a review of the practices at the hospital.
  • Policies and procedures must identify patients at high risk for adverse events and where study might be contraindicated, such as pregnant women, patients with allergies to contrast, and patients with implanted devices having a MRI.



HRM horizonal

Time Limits are Set for False Claims Act Lawsuits

The U.S. Supreme Court recently ruled on a case that may allow hospitals and other healthcare organizations to breathe a little easier.

The court ruled that the statute of limitations is not suspended for certain fraud laws. This would prevent hospitals from trying to defend very old claims. The court overturned the section of the False Claims Act that applied to civil action under the Wartime Suspension of Limitation Act, which was passed to suspend the time period for suing for fraud perpetrated against the federal government. This act will still apply to criminal actions.

This case may lead to more criminal cases but the burden of proof is much higher in criminal actions.

In the case at bar, a qui tam whistleblower claim has been dismissed because an earlier lawsuit had been filed by someone else with the same claim. The claim involved an allegation of fraudulently billing the government for water purification services during the war in Iraq in 2005.

The time frame for bring a false claims suit must be six years from the date of the violation or three years from the date of discovery. However, it must be discovered within 10 years of the violation. Prior to this case, the time period was suspended.

Despite the ruling in the case, it is important to note that the Federal false claims cases show no sign of changes in litigating qui tam whistleblower cases. Also, this case did not involve hospitals or healthcare but the decision applies to cases filed against them.

You can read the Kellogg Brown & Root Servs., Inc. v. United States ex rel. Carter case here.


OIG Work Plan has its First Ever Mid-Year Update

This is the first time ever that the Office of Inspector General work plan has been updated mid-year, so hospitals and other healthcare organizations may not have been on the lookout for an update. It includes items that have been postponed, canceled, completed along with some new items.

Every year the Office of Inspector General publishes the work plan, which is an important document that hospitals generally review carefully to ensure compliance and to update the compliance risk assessments. The work plan summarizes hot spots to watch out for and includes the new and ongoing review and activities of the OIG. It is a blueprint of audit activities and is often reviewed extensively by the hospital compliance committees.

The HHS OIG Mid-Year Update, Fiscal Year 2015, can be found here.


CMS Releases Medicare Billing Data

The Centers for Medicare and Medicaid Services recently published some updated and fascinating information on Medicare billing to physicians and hospitals in the United States.

This data is being published in an effort to make the healthcare system more transparent, affordable, and accountable. The analysis shows, among other things, that anesthesiologists, orthopedic surgeons, ophthalmologists and emergency medicine physicians are among the most highly paid specialists.

It also provides information on Medicare Part D prescription drugs. There were over 1 million healthcare providers who prescribed about $103 billion in prescription drugs. Nexium was the most expensive drug prescribed, followed by Advair Diskus, Crestor, Abilify, Cymbalta, and Spiriva. The most common drug prescribed was Lisinopril, followed by Simvastatin, Levothyroxine Sodium, Hydrocodone-Acetaminophen, and Amlodipine Besylate.

The report also includes information on the 100 most common inpatient stays, involving $62 billion in Medicare payments and over 7 million discharges.

There is also data on 30 selected outpatient procedures performed at over 3,000 U.S. hospitals. Data included 950,000 physicians, nurse practitioners, and other providers which included about $90 billion in Medicare reimbursement. There were 3,900 providers who were paid at least $1 million dollars. A couple of the top ranked physicians are basing legal battles as several have been indicted on Medicare fraud charges.

The average physician was reimbursed about $74,000. The top 10 DRGs by payout included major joint replacement, septicemia, heart failure and shock, pneumonia, COPD, renal failure, esophagitis, and kidney and urinary tract infections. Providers received more money for mental health, sports medicine, and sleep medicine.

The most current data is for the year 2013. Data on hospital inpatient and outpatient charges first came out in the summer of that year. While this is the third annual report on the release of data for Medicare hospital utilization, it is only the second release of data on physician and other supplier and payment information.

You can read all the data here.

For information on the CMS prescriber level Medicare prescriptions data and a list of medications prescribed and costs, go here.


New [WEBINAR] Series:
Sepsis in the Era of 405 Regulations

Join Dr. William F. Paolo as he illuminates the evolving landscape of sepsis management and diagnosis in the light of changing literature and statewide department of health regulations. Earn 1 Continuing Medical Education Credit or nursing contact hour by attending. Live August 13, 2015 from 10 - 11 AM PT & 1 - 2 PM ET. Click here to register.



 AUGUST 2015

8/4/15 – 2 CNE
Nursing Law Update: New MRI Standards & CMS Updates
8/5/15 – 2 CNE
Avoiding Legal Hazards in Documentation: CMS and TJC Requirements for Hospitals and Nurses
8/6/15 – 2 CNE
Hospital Infection Control Worksheet: the Latest from the CMS Office of Standards and Quality

8/11/15 – 1.5 CME & 1.5 CNE
Telemedicine, the Cost-Effective Alternative: Real-time CMS & TJC Standards



8/12/15 – 2 CME & 2 CNE
Clarifying the Confusing CMS Hospital Surgery, PACU, and Anesthesia Standards
8/18/15 – 2 CME & 2 CNE
Give Falls the Slip: TJC & CMS Hospital CoPs & Standards
8/19/15 – 1.5 CNE
CMS Medical Records: What You Need to Know
8/25/15 – 2 CNE
Order Sets, Protocols, Preprinted & Standing Orders: CMS Interpretive Guidelines and Regulation

8/25/15 – 2 CNE
A Pharmacist in the ED:
Improve Safety and Reduce Errors