CMS Radiology and Nuclear Medicine Hospital Conditions of Participation

This program will cover all of the hospital radiology and nuclear medicine standards require by hospitals from CMS. Even though CMS rewrote all of the hospital conditions of participation in radiology and nuclear medicine on July 10, 2015, there are some hospitals that are still struggling to comply. If a surveyor showed up at your door tomorrow would you be able to demonstrate compliance with the 41 pages of changes? Every hospital that accepts Medicare or Medicaid must be in compliance with these regulations and interpretive guidelines.

These address the issue that ionizing radiation can cause cancer and that radiology services are not without risk. Patient exposure to radiation has doubled in twenty years. The amount of ionizing radiation from a CT scan is significantly greater and patients may receive several over their lifetime. In fact, there are 80 million studies done every year. The FDA has taken initiative to reduce unnecessary radiation exposure. The FDA wants to make sure it is justified to use it and dose optimized so the lowest dose is used. This is referred to as low as reasonably achievable. CMS discusses safety precautions a hospital should do to decrease radiation exposure.

This program will cover the MRI requirements. There are many policies and protocols that are now required. This program will help hospitals understand all the radiology and nuclear medicine conditions of participation to help prevent receiving a deficiency.

• Recall that CMS rewrote has radiology and nuclear medicine provisions in the hospital CoP manual
• Discuss that there are a number of policies and procedures required for radiology by CMS
• Describe that the hospital must have diagnostic radiology services that meet standards of care and standards of practice
• Recall that an order is needed for any radiology or nuclear medicine test.

• How to locate a copy of the current CMS CoP manual?
• The risk of ionizing radiation
• Increased patient exposure and the risk of cancer
• Safety precautions to decrease radiation exposure
  • Trained staff, identify high-risk patients, appropriate shielding, inspect and calibrate the equipment
• FDA initiative to reduce unnecessary radiation exposure
• Diagnostic radiology and standards
• Therapeutic radiology and standards
• Required policies and procedures
• CT scans, radiation therapy, ultrasound, MRI. DEXA scan etc.
• Radiology services to meet the needs of patients
• Direct service or through contractual agreements
• Teleradiology
• Order needed
• Badge tests or exposure meters for radiation
• Must be provided in accordance with the standard of care
• Monitoring for quality and safety in radiology services
• Blue boxes
• Need qualified director of radiology
• Reports signed by the practitioner who interpreted them
• Record retention period
• Nuclear Medicine guidelines

Radiology department director, radiology medical director, radiology staff, patient safety officer, risk manager, compliance officer, regulatory affairs officers, chief operating officer, risk management, chief medical officer (CMO), emergency department physicians, clinic physicians, physicist, education department staff, chief nursing officer, hospital legal counsel, or any person in charge to ensure compliance with CMS guidelines on radiology and nuclear medicine.