Imaging experts question validity of new CMS quality measure aimed at reducing CT radiation exposure

Medical imaging experts are questioning the validity of a new Centers for Medicare & Medicaid Services quality measure aimed at reducing radiation exposure from CT exams. 

CMS finalized adoption of the new radiology measure in 2023 after its endorsement by the National Quality Forum. Titled “Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults,” the metric provides a standardized method for discouraging unnecessarily high dosages. 

Given industry chatter around this change, the American Association of Physicists in Medicine recently convened a panel of experts to discuss the ramifications. Their findings—published in the American Journal of Roentgenology—outline numerous concerns with implementation.

“While the measure is well-intentioned and noise is a reasonable balancing metric to radiation output under standardized conditions, the measure’s initial iteration has a host of issues and ambiguities, including technical in congruencies and operational barriers, hindering implementation,” lead author Jered R. Wells, PhD, a radiation physicist with Duke Health in Durham, N.C., and colleagues note. “This detailed review of the measures highlights many of these problematic considerations. Without clarity on these issues, the measure will not achieve its intended impact and may lead to unintended—possibly adverse—consequences on patient care.”

The panel included a diverse collection of stakeholders, representing clinical practice, industry (Siemens Healthineers and Canon), academia and professional societies. CMS has incorporated the new measure into quality-based programs that dictate hospital and physician payment, with measure reporting beginning in January 2025. Wells and colleagues devised a list of 20 “issues and ambiguities” in the measure. 

They noted uncertainty around which practice settings must report the measure, versus when it’s optional. Wells et al. urged hospital outpatient imaging facilities to plan for the measure’s mandatory reporting phase in 2027 and consider taking part in voluntary reporting to “gain familiarity with proper data collection.” Hospitals and MIPS (Merit-based Incentive Payment System)-participating clinicians also should “carefully” weigh the impact of selecting this measure, versus other options. 

Experts also highlighted uncertainties around how inpatient and outpatient designations can be systematically maintained, given the diversity of practice settings and status changes across care episodes. They encouraged CMS to specify a single, clear method for patient admission determination (for example, their status at the time of CT imaging compared to at billing). This would prevent double-reporting or inconsistencies among practices, which could introduce “performance biases.” Until this occurs, imaging providers should select and maintain a single, auditable method for determining patient admission status 

Wells and colleagues explore several other issues relevant to radiology groups. They include ambiguity around how to manage combination studies in accordance with the measure, potential IT burden and security concerns, and how users can contest results they believe are illogical. The American Association of Physicists in Medicine said it remains hopeful imaging stakeholders can work with CMS on modifications.

“Transparency and stakeholder engagement are essential for effective quality initiatives in medicine. We wrote this paper to call attention to issues and ambiguities with the CMS measure, and we look forward to working with CMS to address these issues and continue the culture of quality and safety that has developed in CT imaging over the past two decades,” M. Mahesh, PhD, president of the AAPM, said in a statement from the association, shared Tuesday. 

“We're confident that we can get this right by working together,” he added later.