This bill changes Medicare rules for outpatient medical imaging orders. It updates section 1834(q) of the Social Security Act. Starting January 1, 2026, clinical decision support mechanisms that help ordering professionals must provide specified data to the Secretary of Health and Human Services. The bill moves the compliance date to January 1, 2026 and requires qualified clinical decision support mechanisms to maintain and report information the Secretary specifies. It requires the furnishing professional to include the ordering professional's national provider identifier (NPI) on the claim for the imaging service.
The bill creates a process to measure each ordering professional's compliance rate with the requirement to consult a qualified clinical decision support mechanism. The Secretary will use data from approved decision support mechanisms to calculate a compliance rate for each ordering professional and will designate those with rates below a Secretary-set threshold as "low compliant" ordering professionals. Certain orders are excluded when calculating the rate, including orders listed as exceptions in the bill.
The bill adds specific exceptions to the requirement to consult decision support: imaging ordered as part of clinical trials; imaging ordered by small practices of 15 or fewer ordering professionals or by practices in a health professional shortage area located in a rural area; and specific screening services (mammography, lung cancer screening by CT, CT colonography, and other preventive or screening imaging the Secretary designates). It also lists that other payment systems may apply as determined by the Secretary.
The bill requires the Secretary to provide guidance or rules on how decision support mechanisms should report data, and it requires a study and report to Congress by January 1, 2031 and every 5 years after. That study must discuss compliance rates, impacts on imaging use, and possible ways to improve compliance, including prior authorization or payment adjustments as examples. Finally, when specifying appropriate use criteria and qualified mechanisms, the Secretary must substantially follow the approach described in 42 C.F.R. 414.94 as of January 1, 2023.
No publicly available information on cost estimates or budgetary effects is included in the bill text. The bill establishes reporting and data requirements and directs the Secretary to set reporting formats, but the text does not provide cost figures.
No publicly available information on proponents' stated arguments or rationale is included in the bill text or metadata.
No publicly available information on opponents' stated arguments or concerns is included in the bill text or metadata.