I 

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. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Excellence in Diag5 nostic Imaging Utilization Act of 2013’’. 


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1 SEC. 2. APPROPRIATENESS REQUIREMENTS FOR CERTAIN 

2 ADVANCED DIAGNOSTIC IMAGING SERVICES. 

3 (a) IN GENERAL.—Section 1834 of the Social Secu4 rity Act (42 U.S.C. 1395m) is amended by adding at the 

5 end the following new subsection: 

6 ‘‘(p) APPROPRIATENESS REQUIREMENTS FOR CER7 TAIN ADVANCED DIAGNOSTIC IMAGING SERVICES.— 

8 ‘‘(1) IN GENERAL.— 

9 ‘‘(A) IN GENERAL.—Beginning with Janu10 ary 1, 2015, with respect to applicable ad11 vanced diagnostic imaging services furnished in 

12 an outpatient setting and for which payment is 

13 made under— 

14 ‘‘(i) the technical or professional com15 ponent of the fee schedule established 

16 under section 1848(b); or 

17 ‘‘(ii) the prospective payment system 

18 for hospital outpatient department services 

19 under section 1833(t), 

20 payment for such services may only be made if 

21 the requirements of this subsection are met. 

22 ‘‘(B) APPLICABLE ADVANCED DIAGNOSTIC

23 IMAGING SERVICES.—For purposes of this sub24 section, the term ‘applicable advanced diag25 nostic imaging services’ means advanced diag26 nostic imaging services (as defined in subsection 


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1 (e)(1)(B)) for which defined appropriate use 

2 criteria (and related guidelines) have been— 

3 ‘‘(i) developed or endorsed by national 

4 professional medical specialty societies; and 

5 ‘‘(ii) selected by the Secretary for pur6 poses of this subsection in consultation 

7 with national professional medical specialty 

8 societies and other stakeholders. 

9 ‘‘(C) CONSTRUCTION IN INSTANCES OF

10 MULTIPLE APPLICABLE APPROPRIATE USE CRI11 TERIA.—Nothing in this subsection shall be 

12 construed as preventing the Secretary, in the 

13 case that there are multiple appropriate use cri14 teria (and related guidelines) that are applica15 ble to a particular advanced diagnostic imaging 

16 service (or a specific set of clinical indications), 

17 from selecting more than one criterion (or more 

18 than one guideline) under subparagraph 

19 (B)(ii)(II). 

20 ‘‘(D) PERIODIC REVISION.—The Secretary 

21 may periodically revise the list of applicable ad22 vanced diagnostic imaging services under this 

23 paragraph. 


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1 ‘‘(2) DEVELOPMENT AND MAINTENANCE OF IM2 AGING APPROPRIATENESS REGISTRIES BY MEDICAL

3 SPECIALTY SOCIETIES.— 

4 ‘‘(A) IN GENERAL.—Not later than April 

5 1, 2014, the Secretary shall qualify registries 

6 that are developed and maintained by national 

7 professional medical specialty societies. 

8 ‘‘(B) REQUIREMENTS.—Registries quali9 fied under subparagraph (A) shall meet the fol10 lowing requirements: 

11 ‘‘(i) The registry shall document— 

12 ‘‘(I) the use of an approved elec13 tronic clinical decision support tool (as 

14 described in paragraph (3)) in connec15 tion with the ordering and perform16 ance of an applicable advanced diag17 nostic imaging service; 

18 ‘‘(II) whether orders for applica19 ble advanced diagnostic imaging serv20 ices were consistent with related ap21 propriate use criteria (including an 

22 appropriateness score where available 

23 from the approved electronic clinical 

24 decision support tool); 


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1 ‘‘(III) the clinical indication for 

2 the applicable advanced diagnostic im3 aging services ordered; and 

4 ‘‘(IV) in situations where an 

5 order for an applicable advanced diag6 nostic imaging service is not con7 sistent with the related appropriate 

8 use criteria, the rationale of the order9 ing or furnishing supplier or provider 

10 (as the case may be) for such incon11 sistency. 

12 ‘‘(ii) The registry shall be structured 

13 to allow access to data for future research, 

14 provide a centralized analysis of the data 

15 submitted, including the impact on utiliza16 tion changes for applicable advanced diag17 nostic services, and provide connections 

18 with existing medical society registries. 

19 ‘‘(iii) The registry shall generate re20 ports on at least a quarterly basis pro21 viding feedback to suppliers and providers 

22 that order and furnish applicable advanced 

23 diagnostic imaging services on the ordering 

24 activity of the supplier or provider and re25 lated appropriate use criteria metrics. 


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1 ‘‘(C) MULTIPLE QUALIFIED REGISTRIES.— 

2 In the case where more than one registry is de3 veloped under this paragraph, the Secretary 

4 shall ensure that each registry receives stand5 ardized data such that the data may be com6 bined and compared across registries. 

7 ‘‘(D) PERIODIC UPDATING.—The Secretary 

8 shall periodically update the list of registries 

9 qualified under this paragraph. 

10 ‘‘(3) LISTING OF QUALIFIED SUPPLIERS OF AP11 PROVED ELECTRONIC CLINICAL DECISION SUPPORT

12 TOOLS.— 

13 ‘‘(A) IN GENERAL.—Not later than July 1, 

14 2014, the Secretary shall publish a list of quali15 fied suppliers of approved electronic clinical de16 cision support tools, in accordance with the pro17 visions of this paragraph. 

18 ‘‘(B) STANDARDS.— 

19 ‘‘(i) IN GENERAL.—The Secretary, in 

20 consultation with the medical specialty so21 cieties described in paragraph (2)(A), shall 

22 establish standards for the approval of 

23 electronic clinical decision support tools 

24 provided by qualified suppliers. 


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1 ‘‘(ii) STANDARDS.—The standards es2 tablished under clause (i) shall include the 

3 ability of such tool to— 

4 ‘‘(I) use only standards and 

5 guidelines developed by national med6 ical specialty societies; 

7 ‘‘(II) capture the clinical indica8 tion for the applicable advanced diag9 nostic imaging services ordered, se10 lected from the related appropriate 

11 use criteria; 

12 ‘‘(III) accurately deliver to the 

13 ordering clinician appropriate use cri14 teria (and related guidelines) for ap15 plicable advanced diagnostic imaging 

16 services, regardless of the physician 

17 specialty (if any) from which the cri18 teria or guidelines originated or to 

19 which the criteria or guidelines are di20 rected; 

21 ‘‘(IV) in the case where there are 

22 multiple standards or guidelines appli23 cable to a particular service or a spe24 cific set of clinical indications, indiVerDate Mar 15 2010 02:55 Dec 13, 2013 Jkt 039200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\H3705.IH H3705

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1 cate the standards or guidelines that 

2 are being applied; 

3 ‘‘(V) determine the appropriate4 ness of orders for such services; 

5 ‘‘(VI) submit standardized data 

6 to one or more registries qualified 

7 under paragraph (2) that is sufficient 

8 for such registries to meet their docu9 mentation obligations under that 

10 paragraph; 

11 ‘‘(VII) be regularly and timely 

12 updated; 

13 ‘‘(VIII) generate a unique elec14 tronic identifier (referred to in this 

15 subsection as a ‘Clinical Decision Sup16 port Number’) that documents the 

17 fact that the clinical decision support 

18 tool was consulted by the ordering 

19 supplier or provider in connection 

20 with the ordering of an applicable ad21 vanced diagnostic imaging service; 

22 and 

23 ‘‘(IX) perform other functions 

24 determined to be necessary by the 

25 Secretary in consultation with the 


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1 medical specialty societies described in 

2 paragraph (2)(A). 

3 ‘‘(C) DESIGN.—An approved electronic 

4 clinical decision support tool under this para5 graph— 

6 ‘‘(i) may use a web-based portal, or be 

7 imbedded into an electronic health record 

8 system or other health information tech9 nology tool; and 

10 ‘‘(ii) shall meet the privacy and secu11 rity standards under the regulations pro12 mulgated pursuant to the Health Insur13 ance Portability and Accountability Act of 

14 1996. 

15 ‘‘(D) USAGE AND CONVENIENT ACCESS RE16 QUIREMENTS.—The Secretary shall only include 

17 in the list published under this paragraph ap18 proved electronic clinical decision support tools 

19 provided by suppliers who— 

20 ‘‘(i) attest that they have obtained 

21 permission to incorporate appropriate use 

22 criteria (and related guidelines) developed 

23 by national medical specialty societies; and 


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1 ‘‘(ii) demonstrate that they can pro2 vide convenient access to such a tool via a 

3 secure web-based portal at no cost to— 

4 ‘‘(I) suppliers and providers who 

5 order and furnish applicable advanced 

6 diagnostic imaging services under this 

7 title; and 

8 ‘‘(II) the Federal government. 

9 ‘‘(E) PERIODIC UPDATING.—The Secretary 

10 shall periodically update the list of qualified 

11 suppliers of approved electronic clinical decision 

12 support tools that meet the standards estab13 lished under subparagraph (B) and the other 

14 requirements of this paragraph. 

15 ‘‘(4) CONSULTATION REQUIREMENT.—The Sec16 retary shall require that, as a condition of participa17 tion in the program under this title, suppliers and 

18 providers who order an applicable advanced diag19 nostic imaging service shall agree to consult an ap20 proved electronic clinical decision support tool listed 

21 pursuant to paragraph (3) in connection with such 

22 order. 

23 ‘‘(5) PAYMENT FOR SERVICES CONTINGENT

24 UPON REGISTRY SUBMISSION.— 


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1 ‘‘(A) IN GENERAL.—With respect to an ap2 plicable advanced diagnostic imaging service, 

3 payment for the technical or professional com4 ponent of such service under the fee schedule 

5 established under section 1848(b) or under the 

6 prospective payment system for hospital out7 patient department services under section 

8 1833(t) may only be made if the documentation 

9 accompanying any such claim for payment dem10 onstrates that an approved electronic clinical 

11 decision support tool listed pursuant to para12 graph (3) was consulted and the required infor13 mation was submitted to a registry qualified 

14 under paragraph (2). 

15 ‘‘(B) DEMONSTRATION OF COMPLIANCE.— 

16 Compliance with the requirements under sub17 paragraph (A) may be demonstrated by the in18 clusion of a Clinical Decision Support Number 

19 with the claim for payment. 

20 ‘‘(6) EXEMPTIONS.— 

21 ‘‘(A) SIGNIFICANT HARDSHIP EXEMP22 TION.—The Secretary may, on a case-by-case 

23 basis, exempt a supplier or provider to whom 

24 this subsection would otherwise apply if the 

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1 newal, that compliance with this subsection 

2 would result in a significant hardship, such as 

3 in the case of a supplier or provider who lacks 

4 access to an electronic records system or high5 speed Internet access. 

6 ‘‘(B) EMERGENCY SERVICES EXEMP7 TION.—Applicable advanced diagnostic imaging 

8 services ordered emergently as part of an emer9 gency medical evaluation shall not be subject to 

10 the requirements of this subsection. 

11 ‘‘(C) CLARIFICATION OF INAPPLICABILITY

12 TO INPATIENT SERVICES.—Advanced diagnostic 

13 imaging services ordered for inpatients and for 

14 which payment is made under part A are not 

15 subject to the requirements of this subsection. 

16 ‘‘(7) LIMITATIONS.—The Secretary may not 

17 utilize the authority provided under this subsection 

18 to— 

19 ‘‘(A) impose any requirement that a sup20 plier or provider obtain approval to order an 

21 advanced diagnostic imaging service before per22 forming such service or any other requirement 

23 for prior authorization with respect to such 

24 service; or 


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1 ‘‘(B) use approved electronic clinical deci2 sion support tools to make claims payment de3 terminations under this title. 

4 ‘‘(8) RULEMAKING REGARDING PATIENT SAFE5 TY.—The Secretary shall promulgate regulations to 

6 address situations in which a supplier or provider, 

7 prior to performing an applicable advanced diag8 nostic imaging service for an individual, reasonably 

9 believes that the service ordered, if performed, would 

10 pose a safety risk to the individual and that a dif11 ferent imaging service is more appropriate under the 

12 circumstances. Such regulations shall define cir13 cumstances in which the supplier or provider may 

14 change the order to an imaging service the supplier 

15 or provider determines is more appropriate.’’. 

16 (b) COMPLIANCE WITH APPROPRIATENESS REG17 ISTRY TREATED AS SATISFACTORY QUALITY REPORT18 ING.—Section 1848(m)(3) of the Social Security Act (42 

19 U.S.C. 1395w–4(m)(3)) is amended— 

20 (1) by redesignating subparagraph (F) as sub21 paragraph (H); and 

22 (2) by inserting after subparagraph (E) the fol23 lowing new subparagraphs: 


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1 ‘‘(F) SATISFACTORY REPORTING MEAS2 URES THROUGH PARTICIPATION IN IMAGING AP3 PROPRIATENESS REGISTRY.— 

4 ‘‘(i) IN GENERAL.—For 2015 and 

5 subsequent years, the Secretary shall treat 

6 an eligible professional described in clause 

7 (ii) as satisfactorily submitting data on 

8 quality measures under subparagraph (A) 

9 if, instead of reporting measures under 

10 subsection (k)(2)(C), the eligible profes11 sional provides evidence, in a form and 

12 manner specified by the Secretary, dem13 onstrating that the registry submission re14 quirements under section 1833(p)(5) have 

15 been complied with with respect to not less 

16 than 90 percent of claims for applicable 

17 advanced diagnostic imaging services (as 

18 defined in section 1833(p)(1)(B)) sub19 mitted by the eligible professional in the 

20 year. 

21 ‘‘(ii) ELIGIBLE PROFESSIONAL DE22 SCRIBED.—For purposes of clause (i), an 

23 eligible professional described in this clause 

24 is an eligible professional who furnishes 

25 the technical or professional component of 


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1 applicable advanced diagnostic imaging 

2 services (as so defined). 

3 ‘‘(G) SATISFACTORY REPORTING MEAS4 URES THROUGH PARTICIPATION IN IMAGING AP5 PROPRIATENESS REGISTRY.— 

6 ‘‘(i) IN GENERAL.—For 2015 and 

7 subsequent years, the Secretary shall treat 

8 an eligible professional described in clause 

9 (ii) as satisfactorily submitting data on 

10 quality measures under subparagraph (A) 

11 if, in lieu of reporting measures under sub12 section (k)(2)(C), the eligible professional 

13 provides evidence, in a form and manner 

14 specified by the Secretary, demonstrating 

15 that they have complied with the consulta16 tion requirements under section 1833(p)(4) 

17 with respect to not less than 90 percent of 

18 claims for applicable advanced diagnostic 

19 imaging services (as so defined) submitted 

20 by the eligible professional in the year. 

21 ‘‘(ii) ELIGIBLE PROFESSIONAL DE22 SCRIBED.—For purposes of clause (i), an 

23 eligible professional described in this clause 

24 is an eligible professional who orders appliVerDate Mar 15 2010 02:55 Dec 13, 2013 Jkt 039200 PO 00000 Frm 00015 Fmt 6652 Sfmt 6201 E:\BILLS\H3705.IH H3705

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1 cable advanced diagnostic imaging services 

2 (as so defined).’’. 

3 (c) CONFORMING AMENDMENT.—Section 

4 1833(t)(16) of the Social Security Act (42 U.S.C. 

5 1395l(t)(16)) is amended by adding at the end the fol6 lowing new subparagraph: 

7 ‘‘(E) APPLICATION OF APPROPRIATENESS

8 REQUIREMENTS FOR CERTAIN ADVANCED DIAG9 NOSTIC IMAGING SERVICES.—For provisions re10 lating to the application of appropriateness re11 quirements for certain advanced diagnostic im12 aging services, see section 1834(p).’’. 

Æ 


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