03/26/2016     Michael L. Brody, DPM

Medicare X-Ray Reimbursement Cuts on the Horizon

One of the major advantages of DR over CR is
the reduced dose of radiation necessary to
obtain a high quality image. This can be a
significant advantage when you think of
radiation dosage for chest x-rays, hip x rays
and other imaging studies. When it comes to
foot studies, the radiation dosage is already
so low a 50% reduction in dosage is not as
significant. That being said, when regulations
are written, the regulation is based upon the
entire industry. As a result, DR is viewed as
providing a significant safety benefit over CR.

A second major advantage of DR over CR is speed
of image. A DR image is immediate and there is
a delay between exposure of the phosphor plate
and the time when the image can be viewed,
checked for quality of image (and the need to
repeat the study) and viewed by the clinician.
This can be huge in emergency rooms, trauma
centers and other facilities where minutes are
of the essence.

I do not see the couple of minute delay to be a
significant factor in quality of care in most
podiatry offices.

The digital images with both DR and CR can be
manipulated and enhanced and both are FDA
regulated. I have not seen a single paper that
demonstrates a significant difference in
diagnostic quality that will impact the average
podiatry practice. For podiatric applications
I do not believe that DR has a significant
diagnostic advantage of CR for the great
majority of podiatric pathology.

In addition if I am looking at a pathology that
requires the most sensitive studies, I am more
likely to refer that patient to a radiology
provider for an advanced study such as MRI or
CT.

The differences in DR and CR do warrant the
government implementing a pay differential for
the different technologies. But it is important
to understand the ‘global view’ and understand
that in certain environments, DR does have
significant patient benefits. With the cost of
purchasing CR and DR being comparable, if you
currently use ‘wet films’ now is the time to
upgrade to a DR system.

If you already have a CR system, there is no
compelling reason to upgrade to DR at this time
(At least in my opinion). But you may find that
there are providers who wish to upgrade their
existing CR systems to DR systems and you may
find some nice deals on existing used CR
systems.

Both CR and DR systems do provide significant
benefits over wet films for podiatrists,
especially with the use of the image enhancing
software that both types of systems provide. I
currently have a CR system at my office and it
works just fine. If I were to replace that
system today I would select a DR system, but
since it works fine I do not have any plans to
change my system.

Michael L. Brody, DPM, Commack, NY

Other messages in this thread:

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03/24/2016    Raymond F Posa, MBA

Medicare X-Ray Reimbursement Cuts on the Horizon (Lawrence Kosova, DPM)

I have to take issue with Dr. Kosova claiming
that my post was full of misinformation. As a
HIPAA and IT professional, providing advice and
guidance to the world of Podiatry for over 15
years, I always strive to provide correct and
accurate information. In my prior post, I was
answering a reader’s question regarding the
upcoming cuts in x-ray reimbursements and I
provided broad explanations as to the reasoning
behind the government’s reasoning.

Dr. Kosova, having missed the point, decided to
pick out a single manufacturers product and
attempts to broadly paint all DR systems with
the same brush. I can only assume Dr. Kosova’s
“opinion” is based upon some anecdotal
experience he has had with one particular x-ray
system. The first erroneous statement that Dr.
Kosova makes is that a CR image is considered
the closest to film especially from an auto-
load CR. First regardless of how a CR film
plate is loaded, manually or auto-load makes no
difference in the image quality, it is still
the same type of plate being used. All of the
radiologists that I work with say hands down
the digital DR images are far superior to any
of the older technologies.

As for Dr. Kosova’s assertion about doctors
seeing image quality degrade over time,
recalibration being necessary, damaged sensors,
unreadable holes, all of this is true for one
single manufacturers product (I know which
manufacturer he is referring to). I can tell
you I have first-hand experience with many
manufacturers products, both CR and DR and
these issues that Dr. Kosova raised are unique
to one particular manufacturer, not to all DR
units.

Most of the DR units I have seen and worked
with, do not have this image loss and never
require re-calibration.

As for the claim that a DR installation is much
more costly with expensive installation
requiring modification to your existing x-ray
by a state certified technician, annual
calibration; is a broad brush over
simplification. The installation and
calibration requirements are unique to each
state, many states do not require any
additional state inspections when going from
Chemistry or CR to DR. In all three types of X-
Ray systems they generally are all using the
same intensifier! The most common in Podiatry
is the X-Cel which is often retrofitted to your
new x-ray system when you upgrade from
chemistry or CR to DR.

Dr. Kosova speaks of annual support fees of
$1,000 -$2,000, again those software support
fees are unique to particular companies. Some
companies like A2D2 have free lifetime software
updates and have no annual maintenance fee.

Dr. Kosova goes on to speak of the only real
expense of the CR unit used with a manual
system getting damaged. This is not true. CR
plates cost upwards of $800 each and they do
get damaged over time and have to be replaced,
while the manual CR units are prone to higher
incidents of damage from mis-handling. I have
seen auto-loading units damage the plates with
their rollers while removing the plates from
their cassettes, resulting in permanent lines
being etched on the plates. Think of a fax that
comes through with a line on it or if you use a
re-manufactured toner cartridge in a printer
and you have a line on all of your documents.
The same happens when the roller damages a CR
plate, you have lines across your images.

As for Dr. Kosova’s claims as to the speed of
the CR unit, seeing is believing. Here is a
link for the YouTube video of the side by side
comparison https://www.youtube.com/watch?
v=upogkGz6D6U. It should be noted that the CR
unit being used here is not an entry level $30k
model but a much faster $60K version, you can
see the difference in productivity between the
CR and the DR.

The bottom line is, everybody has an opinion,
but not all opinions should be given equal
weight.

Disclosure: I do not work for nor receive
compensation from any x-ray company.

Raymond F Posa, MBA, Farmingdale, NJ

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03/23/2016    Lawrence Kosova, DPM

Medicare X-Ray Reimbursement Cuts on the Horizon (Raymond F Posa, MBA)

Mr. Posa's post is full of misinformation. The
truth is that a CR image is still considered
closest to film quality, (especially an auto-
load CR) and the expense of having a DR system
is truly significant. Many doctors who have
purchased a DR have gradually seen their image
quality decrease with continued x-ray
radiation, requiring regular expensive annual
recalibration and finding themselves in a
situation where they again need to upgrade or
replace within as early as 5 years.

This recalibration process is done via software
where it is determined which sensors or pixels
have gone bad and blanks out the damaged area,
rather than having holes or unreadable
information, masking and smoothing it over
resulting in missing information.

A DR system is also much more costly with
expensive installation charges requiring
modification to your existing x-ray by a state
certified technician, annual calibration (with
annual support fees of $1000 - $2,000 per
year), and as mentioned…gradual image
degradation clearly noticeable within 5 years.

The only real expense of a CR would be where
the phosphor imaging plates used with manual
load CR systems can be damaged with
mishandling, depending on how careful the
technician is...however an auto-load CR system
eliminates this problem. The processing time
for an auto-load CR is about 30 seconds to
obtain an image, and about another 30 seconds
for erasure, resulting in a total processing
time of about 1 minute.

The 7% payment reduction only involves Medicare
going into effect next year, with 6 years later
in 2023 proposed to 10%. However the estimated
loss in revenue will in no way cover the
additional expense for a small office to
convert to DR for the reasons mentioned above.

The only other reason I can think why the
government has included CR in reimbursement
reduction, (other than from outside special
interests) might be the disposal of used plates
containing Phosphor, but they can be recycled.

This is just another way the small office
practitioner is being hit with continuous
government reduction in income. Hopefully, when
the new regime takes office next year, and
pressure from medical organizations....smarter
minds will persevere.

Lawrence Kosova, DPM, Chicago, IL

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03/18/2016    Raymond F Posa, MBA

Medicare X-Ray Reimbursement Cuts on the Horizon

Dr. Kass asks a good question and one that is
often not discussed or disclosed at the time of
the sale of a CR x-ray unit. The difference
between CR and DR is that CR is an analog
process and DR is a digital process. What
happens in a CR x-ray is that the x-ray
irradiates a phosphate plate, that plate is
then put in a processor which looks at the
irradiated portions of the plate and then
computes an image from the “hot spots” and
creates the image.

In the DR system instead of a phosphate plate,
it uses a plate with CCD receivers that capture
the x-rays and create a direct digital image.
Think of the two types of images this way, DR
is like taking a picture with your digital
camera and loading it to your computer while CR
is like taking a photograph of the same image and
running it through a scanner and then viewing
it on your computer. The extra steps in the CR
methodology make it slower and less efficient
than DR. Also when you scan an image the
quality is never as high as an original.

So the rationale behind the government’s
decision is reflected in the reduction steps,
the goal is to move all studies to 100%
digital, they are more efficient and higher
quality, they recognize that CR is better than
chemistry thus there is less of a reduction in
reimbursement. The writing is on the wall, the
government is not going to tell you that you
can’t use chemistry or CR they are just going
to make it painful to continue to use those
older technologies.

As for a solution, talk to a DR company about
their new offerings. The new systems cost less
than what you paid for the CR unit and the DR
units qualify for an ADA tax deduction which
greatly lowers the cost of ownership. You will
also see a six fold increase in productivity.
Several years ago when I was writing on this
topic, I conducted a side by side comparison of
a three position study using CR vs. DR and the
DR took about 2 minutes for the three images to
be taken and reach the desktop, the CR took 6
minutes.

If you do choose to upgrade to a DR unit, you
may want to consider donating your CR unit to a
school or community health clinic, you will be
helping an organization that may not have the
financial resources to have an in house X-Ray
and they don’t have to worry about
reimbursements.

Raymond F Posa, MBA – Farmingdale, NJ