CR-DR Transition

MITA FAQ 1-2016 CR to DR Transition

Frequently Asked Questions

Radiography Payment Changes in the Consolidated Appropriations Act 2016 (P.L. 114-113)

Published April 21, 2016
Updated December 12, 2016

 

The CMS FY 2017 final rules for the Hospital Outpatient Prospective Payment System (HOPPS) and the Physician Fee Schedule (PFS) were issued November 14, 2016. CMS intends to implement the film x-ray policy as proposed (see FAQ #1), making no exceptions for mammography, fluoroscopy, radioscopy, or any other service. CMS has not identified specific CPT codes applicable for the reduction. Proposed implementation rules regarding CR reductions in reimbursement are expected to be released July 2017.

Background

On December 18, 2015, President Obama signed into law Consolidated Appropriations Act of 2016, bipartisan legislation which provided funding for the federal government for the 2016 fiscal year (October 1, 2015-September 30, 2016). Within this extensive legislation were radiology provisions related to the reimbursement for analog radiography (film), computed radiography (CR), and digital radiography (DR) imaging services.

The law will be implemented by the Centers for Medicare and Medicaid Services (CMS).  CMS will issue a proposed rule in July 2016 detailing the proposed reimbursement changes, services subject to reductions and a mechanism for recording the type of radiography used.  Following the comment period CMS will release a final rule around November 1, 2016.  It is expected that the rule will follow the same framework that CMS used to implement the CT reimbursement scheme codified in the Protecting Access to Medicare Act of 2014 designed around NEMA XR 29.   Until CMS issues the rule, the exact implementation and impact are unknown.

Frequently Asked Questions

A collection of frequently asked questions (FAQs) follows:

  1. What does the law specifically state?

Medicare reimbursements of the technical component under the Physician Fee Schedule and the Hospital Outpatient Prospective Payment System will be reduced according to the following schedule for radiologic exams conducted using fiIm or CR.  It should be noted that the reductions are not compounded year over year.  The law states “CR is defined as cassette-based imaging which utilizes an imaging plate to capture the image.”

*Reduction from the then current CMS reimbursement rate

  1. What services are likely to be impacted?

CMS will apply the 20% payment reduction to all imaging services that are x-rays taken using film that are delivered in physician offices, free-standing imaging centers, and hospital outpatient departments.  Inpatient acute care hospitals are exempt from payment changes as they are reimbursed under a different payment system.

  1. What is film?

In analog radiography (film), X-ray images are acquired using a cassette that contains an intensifying screen and a sheet of unexposed film. When exposed to X-rays, the intensifying screen converts the X-rays to light, and the light exposes the film to produce a latent image. The cassette is then brought to a darkroom where the exposed film is removed and the latent image is converted to a visible image through conventional chemistry-based film processing. To produce adequate image density, the exposure conditions must be tightly matched to the screen/film combination being used.

  1. What is CR?

In computed radiography (CR), X-ray images are acquired using a cassette that contains a photostimulable phosphor imaging plate (IP). When exposed to X-rays, the IP traps and stores the latent image. The cassette is then brought to a CR reader unit where the latent image is extracted from the IP through laser scanning, and then digitized. The digital image is then processed using image processing algorithms to produce the desired image. Unlike film, CR doesn’t require chemical processing and provides a digital image.

  1. What is DR?

In digital radiography (DR), X-ray images are acquired using a detector that contains a conversion layer and electronic readout layer. When exposed to X-rays, the conversion layer converts X-rays to light and then to electrical charges. The image is then read out, digitized and transmitted out of the detector. The digital image is then processed using image processing algorithms to produce the desired image. Unlike film and CR, DR can display images in near real time.

  1. What are the Pros/Cons of film vs. CR vs. DR?

CR and DR generally deliver a higher quality image at a lower dose than film. CR and DR also have workflow advantages over film and produce digital images. DR has further workflow advantages, can display images in near real time, and in most cases has improved dose efficiency.

  1. I’m a healthcare provider, how do I determine the type of my equipment?

This is complicated as systems are identified differently by the various manufacturers.  Older radiography systems that were originally installed using film may have been upgraded to CR or DR.  Equally, radiography systems that were installed with CR initially may have been upgraded to DR.  The best method is to consider the image acquisition system separate from the patient positioning and the X-ray emitting equipment when asking/answering this question.  Film is easily identifiable by the use of a dark room and processing chemicals.  The difference between CR and DR may be more subtle because both produce a digital image.  Unlike DR, CR typically requires a CR reader unit where the latent image is extracted from the IP through laser scanning. If you are unsure, contact the manufacturer of the image acquisition system for further details.

  1. Do imaging providers need to replace the entire X-ray system to avoid lower reimbursement?

No, typically not. The law ties reimbursement to the image acquisition technology – film, CR or DR. Modern radiography systems are basically compatible with more than one acquisition technology. Since the sizes of common film cassettes, CR cassettes, and mobile DR detectors are usually the same, they can be used in many radiography systems. But limitations are possible; for example, large format DR detector sizes may not be compatible with existing X-ray equipment.

  1. I’m a patient, how does this affect me?

Each acquisition technology is capable of producing a diagnostic quality image.  Outwardly, the actual radiologic exam will seem identical to the patient.  Digitally acquired images are typically acquired faster and this may help with patient comfort for exams that require holding a pose while the exam is conducted.   Digital images such as CR or DR are easily electronically portable.  This portability may permit the sharing of images between referring physicians and the radiologists.