The American Academy of Otolaryngology – Head and Neck Surgery (AAO-HNS), with approximately 12,000 members nationwide, is the national medical association of physicians dedicated to the care of patients with disorders of the ears, nose, throat, and related structures of the head and neck. The medical ailments treated by this specialty are among the most common that afflict all Americans, old and young, including hearing loss, balance disorders, chronic ear infections, rhinological disorders, snoring and sleep disorders, swallowing disorders, facial and other cranial nerve disorders, and head and neck cancer.
The AAO-HNS has heard from several members that certain private payers have instituted policies that exclude the specialty of Otolaryngology from reimbursement for imaging services, including Computed Tomography (CT), MRI, and ultrasound, based on their specialty. We have also been informed that some private payers do not provide coverage for the utilization of Cone Beam CT (CBCT) imaging modality services. As such, the AAO-HNS provides this statement in support of otolaryngologist – head and neck surgeons who employ point-of-care imaging when medically necessary and appropriate, in order to improve efficiency and accuracy in diagnosing and managing a patient’s condition.1
The AAO-HNS’s position statement on Point-of-Care Imaging in Otolaryngology states that the AAO-HNS,
…strongly endorses the practice of providing patients with timely, effective, efficient, and patient-centered diagnostic imaging studies and interpretation by appropriate qualified specialists. The American Academy of Otolaryngology-Head and Neck Surgery strongly believes in the provision of high quality comprehensive care to otolaryngology patients. We maintain that point-of-care imaging represents a modality of service that is in line with the Institute of Medicines six dimensions of high quality care; care that is safe, timely, effective, efficient, equitable, and patient-centered. All otolaryngologists receive training in head and neck imaging studies as part of their medical specialty training, and it is a component of the Scope of Knowledge for Board Certification.
Based on residency training received, as well as the additional education (elaborated below) that many otolaryngologists and their practices undergo to receive accreditation by the Intersocietal Accreditation Commission (IAC), we urge all payers to revise their policies and allow otolaryngologists to receive payment for performing and interpreting medically necessary diagnostic imaging within the specialty’s scope of knowledge. Further, we urge private payers to create policies that recognize the benefits CBCT imaging modality services can offer select patients with the course of their care, particularly when evaluating the sinus complexes.
I. Otolaryngologists Possess Extensive Professional Expertise to Perform and Interpret Diagnostic Imaging
The AAO-HNS strongly supports private payers instituting policies that are designed to help ensure patients receive appropriate diagnostic imaging tests, avoid the inconvenience and expense of unnecessary and/or duplicative services, and reduce exposure to unnecessary radiation. While we support opportunities to improve the quality of interpretation of diagnostic imaging as well as the promotion of appropriate imaging use, we remain concerned with policies that fail to categorize otolaryngologist – head and neck surgeons as duly trained specialists for head and neck imaging studies.
In order for otolaryngology – head and neck surgery residency programs to maintain their accreditation, all programs must strictly adhere to the requirements of the Accreditation Council for Graduate Medical Education (ACGME). Under the ACGME, otolaryngology – head and neck surgery residents “must demonstrate proficiency in data gathering and interpretation in areas” including “imaging studies of the head and neck.” In other words, the ACGME has a specific requirement that demands otolaryngology – head and neck surgery residents achieve mastery in head and neck imaging studies as a prerequisite to board-certification. This requirement helps ensure otolaryngology – head and neck surgery residents possess the knowledge and expertise to accurately select, order, interpret and perform imaging studies.
In addition to otolaryngologist – head and neck surgeons needing to demonstrate a proficiency in head and neck imaging during specialty training, many complete Continuing Medical Education (CME) credits that often include courses on head and neck imaging. The AAO-HNS annually offers CME courses specifically tailored to meet the rigorous IAC CME accreditation standards for both initial accreditation and reaccreditation requirements. All of these factors demonstrate the extensive professional expertise our specialists have with performing and interpreting diagnostic imaging, thus helping ensure patients receive appropriate diagnostic imaging studies for the head and neck.
Further, otolaryngologists very frequently perform procedures on patients for whom they have ordered and interpreted imaging (e.g., relating to disorders involving the sinuses, neck, temporal bone). The clinical correlation that can be achieved between intraoperative findings and those on imaging is unsurpassed, both for the individual patient and as the surgeon gains practice experience; as expert as they are, radiologists rarely have such opportunities. In fact, surgeons must have a high level of radiographic interpretive skill (as opposed to merely reading the report) to successfully perform procedures for which imaging is integral to medical/surgical decision making, be it pre-operative or intra-operative with image guidance.
II. Use of Cone Beam Computed Tomography (CBCT) Imaging
The AAO-HNS strongly believes patients should receive the most appropriate imaging modality to help diagnosis their condition. For patients undergoing CT imaging of the paranasal sinuses, skull base and temporal bones, both conventional CT and CBCT imaging are appropriate methods. Because of such, providers should be allowed to decide whether conventional CT or CBCT is the most appropriate imaging modality, so long as it is only performed when absolutely necessary and in the patient’s best interest.
This position not only corresponds with, but is also strengthened by the AAO-HNS’ Clinical Practice Guideline: Adult Sinusitis (September 2007, currently undergoing update)2, which was developed through rigorous methodology (cited by IOM and CMSS) by multidisciplinary guideline panels, including members of the American College of Radiology (ACR). This guideline provides evidence based guidance for physicians and other healthcare professionals to diagnose and manage sinusitis in adults. It also emphasizes appropriate diagnosis, including specific supporting text on the use of radiographic imaging (e.g., plain film radiography, CT, and magnetic resonance imaging) and provides management options including observation, antibiotic therapy, and additional testing.3
When ruling out disease (and saving money on antibiotics) as well as confirming, documenting, and localizing disease, CBCT imaging technology is invaluable. The FDA has approved CBCT and designated it as not considered experimental or investigational. CMS and third party payers consider both conventional and CBCT appropriate for imaging of the paranasal sinuses, skull base and temporal bones in the office setting. The AAO-HNS strongly believes that CBCT should be covered for evaluation of any of the sinus complexes, not just the frontal or sphenoid. Further, we strongly endorse the clinical use of (and reimbursement for) CBCT imaging technology to include indications other than “diagnosis uncertain and suspected acute frontal or sphenoidal sinusitis”, as listed above. Non-contrast CT imaging for sinonasal pathology, independent of modality or technique, is endorsed by the American College of Radiology (ACR) and is outlined in the recently updated ACR Appropriateness Criteria for Sinonasal Disease from June 2010.4
CT imaging for sinonasal pathology primarily involving acquisition of bone window views and intravenous contrast (with conventional CT and MRI imaging) is infrequently indicated. In clinical situations where unusual findings are identified on an initial CT scan (such as bone erosion of the skull base or when a malignant neoplasm is suspected), further imaging may be necessary. In addition, CBCT imaging is compatible with image guidance surgical systems for intra-operative surgical navigation for the indications, for example, sinonasal polyposis and mass.
The use of non-contrast imaging, combined with the fact that CBCT imaging delivers lower radiation dose exposure than conventional CT imaging (in an era where serious concerns exist regarding radiation overexposure and patient safety) makes CBCT a safe and effective imaging modality for the broad range of sinonasal pathology in clinical practice. As such, we strongly encourage private payers provide coverage of CBCT imaging modality services.
III. Intersocietal Accreditation Commission (IAC) Standards and Requirements
In addition to supporting point-of-care imaging, the AAO-HNS also fully supports rigorous accreditation standards and requirements for in-office imaging modalities, including those for conventional CT and CBCT modalities. The AAO-HNS is a founding member of the Intersocietal Accreditation Commission – CT-Division (IAC), an organization designated by CMS5 to accredit suppliers seeking to furnish the technical and professional component of advanced diagnostic imaging services under the Medicare program. The IAC demands standards which either meet or exceed those utilized by other accrediting entities.6
We strongly believe accreditation helps to ensure that those healthcare professionals using imaging equipment in the physician office setting follow the national safety and quality standards7 that are required by the IAC. The IAC requires all interpreting physicians demonstrate that their qualifications are in strict compliance with its rigid standards in order to even be eligible for accreditation. The IAC standards permit three different pathways for physician qualification, each of which requires at least 40 hours of CT relevant CME, a minimum of three hours of documented CME in radiation safety, and then a completion of 15 hours of CT related CME every three years.
An example of one such pathway is the pathway for a physician with an established practice, which is most commonly used by otolaryngologist – head and neck surgeons. Under this criterion, a provider may seek qualification if the physician can demonstrate that he or she has been interpreting CT studies for at least five years, has acquired a minimum of 150 hours Category I CME (obtained over the course of their professional experience) and has interpreted a minimum of 500 CT examinations relative to the organ system(s) with self-attestation. These demanding standards demonstrate that otolaryngologist – head and neck surgeons using in-office modalities accredited by IAC have additional training in performing diagnostic imaging.
Moreover, as an entity accepted by CMS as meeting or exceeding the accreditation standards set out in MIPPA, the AAO-HNS respectfully requests private payers designate the IAC as an appropriate accrediting body and list it as an approved program under any relevant policy. It is important to note that the IAC accreditation program scrupulously evaluates not only the qualifications of the physician, but also the quality of the facility as a whole. Because of such, the AAO-HNS believes providers meeting IAC CT accreditation requirements should not be denied reimbursement merely because they only offer one imaging modality service in their office. Criteria which requires the offering of several different imaging modality services in order to be reimbursed is far too restrictive. Exclusivity and monopolization of diagnostic techniques adversely affects patients; it reduces quality and safety of care, negatively impacts access to appropriate care, increases cost, and does little to address concerns of overutilization.
IV. The AAO-HNS’ Position Statements and Clinical Practice Guidelines (CPG) Benefit Patients Through the Promotion of Better Outcomes, Greater Consistency of Care, Informed Decision-Making and Transparency.
Our regard for providing an unparalleled quality of care to patients with disorders of the ears, nose, throat, and other related head and neck structures cannot be overstated. We strive to provide the highest quality of care to our patients which is why the AAO-HNS routinely works collaboratively with other specialties when producing many of its guidance documents, including its Clinical Practice Guidelines (CPG).
Use of our Clinical Practice Guidelines (CPG) is one way that the AAO-HNS, more specifically its members, increase implementation of evidence into practice. They serve as guides to best practices, a framework for clinical decision making, and a benchmark for evaluating performance. As previously mentioned, our Clinical Practice Guideline: Adult Sinusitis, was developed via a multidisciplinary approach and serves as an invaluable resource to many providers. As such, we respectfully request private payers consider its inclusion as a reference with diagnostic imaging coverage policies.
Similarly, the AAO-HNS position statements are another invaluable tool that we would like to bring to payers’ attention. Position statements draw upon best available evidence and quality products. Further, they clearly articulate the AAO-HNS’ position on clinical procedures or medical services, which are often utilized by our members, other providers, and third party payers. We respectfully request the inclusions of the AAO-HNS’ Point-of-Care Imaging in Otolaryngology position statement as a reference and resource for diagnostic imaging coverage policies in addition to the Adult Sinusitis CPG.
When developing its Appropriateness Criteria for Sinonasal Disease, the American College of Radiology (ACR) sought the expertise from the AAO-HNS. Recognizing the AAO-HNS’ unique and specialized knowledge as it pertains to the head and neck, the AAO-HNS was afforded standing representation on the ACR’s expert panel in this regard. We strongly believe that the collaborative, working relationship the AAO-HNS has established with the ACR in this manner provides further evidence that otolaryngologist – head and neck surgeons are indeed qualified to perform and interpret diagnostic imaging as it pertains to the head and neck.
We are appreciative of all efforts to ensure appropriate use and higher rates of accurate interpretation of diagnostic imaging and understand the value of instilling stringent diagnostic imaging and interpretation criteria to safeguard the quality of care received by payers’ members. While we agree with the dedication to maintaining a high quality of care, we remain concerned with policies that fail to properly classify otolaryngologist – head and neck surgeons as duly trained and qualified providers for performing and interpreting diagnostic images as they pertain to the head and neck. We are also concerned with policies that do not recognize CBCT as an appropriate and beneficial imaging modality.
Given the fact that board-certified otolaryngologists receive training in head and neck imaging as part of their medical specialty training, and the fact that in-office modalities accredited by the IAC must meet rigorous training and safety requirements, the AAO-HNS respectfully requests that board-certified otolaryngologist – head and neck surgeons be considered appropriate specialists to perform and/or interpret diagnostic imaging studies of the head and neck. We strongly believe otolaryngologist – head and neck surgeons more than demonstrate the requisite requirements and qualifications to perform such studies, and therefore should be reimbursed for either the professional and/or technical component of procedures, when medically necessary and appropriate. In addition, we request that private payers consider CBCT as an appropriate imaging modality and allow coverage, when medically necessary and appropriate.
The AAO-HNS thanks all payers for their consideration and welcomes the opportunity to discuss any of the aforementioned issues further. Should any payer have any questions regarding our comments, please do not hesitate to contact the AAO-HNS Health Policy Team at at [email protected]
5 To receive the designation, IAC was required to demonstrate experience in the advanced diagnostic imaging area and to document that its accreditation requirements met or exceeded the standards set out in MIPPA, including requirements for: qualifications of non-physician personnel performing the imaging; qualifications and responsibilities of medical directors and supervising physicians; procedures to ensure the safety of the individuals furnishing the imaging procedure, and of the people to whom services are furnished; and procedures to ensure the reliability, clarity, and accuracy of the technical quality of the diagnostic images produced by the supplier.
1 While the AAO-HNS cannot represent physician members individually on each issue with private payers, we do work to provide resources to assist members on nationwide reimbursement matters. As a result, the AAO-HNS, working with the Physician Payment Policy (3P) workgroup, has developed this statement and a template appeal letter to assist members with their appeal efforts.
3 Please be advised that the AAO-HNS is currently developing an updated guideline, which should be available very shortly.
6 CBCT meets the standards required for CT accreditation by the IAC-CT Division.