Clinical Decision Support

Starting Jan. 1, 2020 - the Protecting Access to Medicare Act (PAMA) requires referring providers to consult appropriate use criteria (AUC) prior to ordering advanced diagnostic imaging services (ADIS) — CT, MR, Nuclear Medicine and PET — for Medicare patients.

CMS will progress with a phased rollout of the CDS mandate:

  • July 2018-December 2019: Voluntary reporting period for early AUC adopters
  • January 2020: AUC program begins with one year “Educational and Operations” testing period (with no penalties on rendering physicians for incorrect reporting)

What You Need to Know

An AUC consult must be documented via a CMS-qualified clinical decision support mechanism (qCDSM). Without a documented consult, rendering providers will not receive Medicare payment for the procedure.

  • The law does not mandate ordering providers strictly adhere to the AUC, just consult AUC. There is no “hard stop” to the ordering process.
  • Emergency department exams are included in this rule – except for the most emergent cases as defined under The Emergency Medical Treatment And Labor Act (EMTALA). Inpatient exams are also exempted. The U.S. Department of Health and Human Services (HHS) may make limited exceptions for rural providers with limited internet connectivity including:
    • Insufficient Internet Access (e.g. rural areas);
    • EHR or CDSM vendor issues (e.g. technical problems, installation or upgrades temporarily impede access to CDSMs, vendors cease operations or CMS de-qualifies a CDSM); or
    • Extreme and Uncontrollable Circumstances (e.g. man-made or natural disasters; area infrastructure issues)

Practices that use a qualified Clinical Decision Support Mechanism (qCDSM) can receive credit towards the Promoting Interoperability (formerly Advancing Care Performance) Category.

  • To receive Merit-based Incentive Payment System (MIPS) Improvement Activity Points and Promoting Interoperability Bonus (if not exempt or choosing to report that category), practices must implement and attest to using a qCDSM during the 2018 reporting period.
  • Organizations interested in maximizing MIPS Positive Payment Adjustment should implement a qCDSM by September 2018 to meet the 90-day Improvement Activity/Promoting Interoperability reporting requirement.
  • Early implementation will help ensure a positive financial impact through MIPS Performance Categories and set the stage for a compliant PAMA implementation.

Misconceptions About AUC/CDS Process

  • Will there will be another delay? The start date for the AUC consultation requirement is fixed at Jan. 1, 2020 and will start with a 12-month educational and operations testing period. During the period, professionals must participate in the program but can avoid claims denials to give CMS an opportunity to make any needed claims processing adjustments before payment are impacted. As a result, Jan. 1, 2021 would be the first date by which rendering professionals’ technical and professional component reimbursement could be denied without a documented consult. CMS expects to use either the CY 2022 or CY 2023 Medicare Physician Fee Schedule rulemaking cycles to define the specifics of the outlier policy. Data amassed during the 12-month educational and operations testing period will not be measured for outlier calculation.
    • Imaging facilities/practices/departments will not have to change their reporting lexicon or approach. Care Select™ Imaging - a digital representation of the ACR Appropriateness Criteria - and likely other CDSM vendors as well - can work with imaging providers to incorporate current lexicon into the system workflow.
    • CDS can be done even if referring and rendering providers do not share a common EHR/EMR system. Care Select™ Imaging – which contains the ACR Select® module, a digital representation of the ACR Appropriateness Criteria - and perhaps other CDSM vendors can serve this function, documenting AUC consultation and providing necessary “identifier” code to include in Medicare imaging claims.
    • Imaging providers will not be competitively disadvantaged by this federal requirement:
      • No rendering provider can receive Medicare payment for an ADIS if the referring provider does not attach a HCPCS/G-codes and modifiers to the referral
      • All radiology providers may refuse Medicare referrals without this documentation, with few exceptions as outlined above
      • Imaging providers cannot perform AUC administrative duties for referrers (as with prior authorization)
      • Ordering providers cannot shift the AUC requirement to radiologists
      • There is no facility “exempt” from PAMA requirements (other than those exceptions outlined above) to which providers can shift this Medicare imaging
      • These factors should quickly result in integration of CDS in referring practices
    • The minimal cost to imaging providers to implement AUC/CDS is far less than losses due to Medicare (and subsequent private payer) reimbursement cuts – and/or radiology benefits management (RBM) denials to follow if AUC/CDS program fails.
    • CDS does not reduce necessary revenue. It helps facilities/departments gain market share by strengthening their ability to accommodate new patients and demonstrates quality to referring providers.
    • This change is not sudden. CMS granted physicians six years to prepare for implementation (April 1, 2014, when PAMA became law – Jan 1, 2020 start date) and is implementing AUC/CDS via the rulemaking process, asking for provider input at every point.
    • CDS can be – and is being – efficiently put in place nationwide. AUC-CDSMs have successfully adopted EHR integration in over 250 health systems and 2,000 acute care facilities in all 50 states.
    • CDS can ultimately reduce administrative burden on imaging providers. It provides data to help demonstrate utilization management and negotiate an end to preauthorization.
    • CDS helps providers engage patients in their care. Providers can use CDS to show them why a certain exam may be (un)necessary. This leads to better shared decision making.
    • All AUC in a given qCDSM need not be consulted. No imaging provider would be penalized in any way for choosing a qCDSM that contains more AUC than another.
      • Providers need only consult the AUC that applies to the individual advanced imaging exam to be ordered.
      • In many cases, particularly when the qCDSM does not contain AUC, consultation can be automatic.
      • A qCDSM is required to have reasonable coverage of Priority Clinical Areas (PCA). There is no defined maximum.
      • Having access to comprehensive AUC enables organizations to manage utilization across all services, which can help eliminate the overhead of prior authorization across all payers.
      • As the PCA will expand, comprehensive coverage can help keep practices ahead of future rulemaking. 

Resources

Background Materials

Videos

What You Need to Do


CARE-SETTING SPECIFIC TIPS

Both technical and professional component claims require evidence of consultation to be payable. Practice setting will influence how practices work with referring providers and adapt workflows. Below are care-setting-specific tips gathered through experience to date.

Hospital Based Practice

  • Ensure that affiliated institutions have integrated qCDSM into their EHR and that the consultation information flows to your revenue cycle applications for professional and technical billing. A good way to measure this is to ensure that the structured indication selected by the ordering provider is available in your interpretation workflow.

Ambulatory Imaging Practice

  • Educate referrers on availability of no fee access points, including via several ambulatory EMR applications.
  • Ensure workflows and integrations to receive electronic orders include consultation information (if available).
  • Become familiar with AUC consultation process and enable referring providers.
  • In some cases, your practice may only receive a unique consultation identifier generated by the qCDSM. You may need to access or integrate with the qCDSM to retrieve claims data.
  • Ideally the structured indication selected by the ordering provider is available in your interpretation workflow.
  • Sign up for/with the qCDSM to become familiar with the process.

Private Practice

  • Ensure your professional billings include the necessary consultation data. This will require that your billing company work to include the consultation data into their processes.
  • Ensure that the systems interacted with include the structured indication selected by the ordering provider.
  • Sign up for/with the qCDSM to become familiar with the process.
     

GENERAL – Across Care Settings

Make sure your IT, medical and professional staff are aware of the approaching CMS deadline.

  • Explain why you are doing this – legislative requirement and quality improvements – via:
    • grand rounds/staff meetings
    • network emails
    • newsletters

Ensure that your IT/informatics team is incorporating AUC into your electronic medical record (EMR) and image ordering and fulfillment systems.

  • Meet with various stakeholders:
    • obtain buy-in from administration
    • obtain buy-in from ordering practitioners
    • obtain buy-in from information systems (IS) and information technology (IT)

Educate relevant staff on how to use the AUC/CDS system you choose – your qCDSM vendor can help.

  • Hold weekly conference calls with vendor, IS/IT and ordering provider leaders
  • Create instruction video and set up mandatory viewing prior to turning on CDS system
  • Distribute PDF instruction manual, newsletters

ACR resources can help

Journal Articles


Related Articles

Clinical Decision Support



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