[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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