Claims Data Analysis to Define Priority Clinical Areas for Advanced Imaging

By Susan Fan, MD , Lionel Levine , Brooke Eckman , Colleen Pelser , Carmen Cunningham , Robert Chiteman, MD , Dr. Juan Arroyo

A summary of findings from claims data from the Medicare population and its use of advanced imaging procedures. This will help CMS establish priority clinical areas for Medicare-appropriate use criteria program for advanced diagnostic imaging services.

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​The Centers for Medicare & Medicaid Services (CMS), through its Coverage and Analysis Group, engaged the CMS Alliance to Modernize Healthcare (CAMH) Federally Funded Research and Development Center (FFRDC) to begin developing efficient and effective processes for managing current and future health technology assessments. This supports CMS’s efforts to enhance access to reasonable and necessary technologies and services for beneficiaries that improve health outcomes, while safeguarding them from potential harms associated with technologies and services that are of questionable value and not proven to improve their health outcomes. CMS relies on this CAMH FFRDC expertise and objectivity to conduct technology assessments that serve only the interests of the government and its beneficiary population. CAMH leveraged its Alliance Partners to bring together the expertise needed to prepare this technical report.

This report presents a summary of findings from claims data from the Medicare population and their utilization of advanced imaging procedures. This report will serve, in part, to help CMS establish priority clinical areas for the Medicare-appropriate use criteria program for advanced diagnostic imaging services.  The analysis presented in this report is a cross-walk on claims data only, derived from the Chronic Condition Data Warehouse (CCW)’s 2014 Part B non-institutional claim line file.  Starting with Healthcare Common Procedure Coding System (HCPCS) advanced imaging procedure codes from Medicare claims, the CAMH team identified the main diagnoses that emerged by volume of instances and used these to establish diagnosis groups. Those groupings allowed the CAMH team to correlate diagnoses to the most common procedures used in 2014. From this, it was surmised how the grouped diagnosis and attendant imaging workup related to everyday practice in terms of disease prevalence.

The CAMH team’s analysis did not consider information found in the patient’s medical record and did not have insight on the patient’s medical history or their clinical outcomes after imaging. The picture that emerged, in terms of common diagnoses for the population receiving Medicare, is that advanced imaging procedures were reasonably matched to the grouped diagnosis codes the team developed, and the corresponding imaging modalities used to investigate them.  This analysis to correlate imaging procedure codes with diagnoses groups derived from claims data pointed to the following as clinical areas to prioritize based on the frequency of occurrence: heart condition, back and neck pain, acute abdominal pain, malignancies, headache and/or head injury, stroke symptoms, pulmonary abnormalities, face and neck injury, and altered mental status.​