Feb. 20 - ACR-RBMA Clinical Decision Support Webinar Question and Answer Session

Q - Can imaging providers provide ordering portals to referring physicians to meet the requirements?

A - The consultation must be done through a qualified clinical decision support mechanism. A list of the qualified mechanism may be found https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/CDSM.html. Three of the qualified mechanisms include free online portals.

Q - Can Imaging providers access CDS on behalf of ordering physicians, if EMR orders are passed to them by referrers.

A- No, the law and regulations are clear that the AUC consultation must be performed by the referring provider. The 2019 Medicare Physician Fee Schedule Final Rule did include language allowing "clinical staff under the direction of the ordering professional" to perform the consultation, but again, this must be a professional within the referring provider's office.

Q - Does this new system include clinical decision support for other orders that are often ordered along with imaging? For example: lab tests or specialty consults?

A - No, the AUC mandate only applies to advanced diagnostic imaging services (CT, MR, PET, nuclear

Q - With PQRS if a claim went without the PQRS code you could not submit a subsequent claim with the code to get credit. Can the code be added on a later claim to get favorable payment?

A - No, the AUC consultation information must be submitted with the imaging exam claim.

Q – Our EMR vendor in our emergency department (ED) does not intend to interface a CDSM into their EMR. It will provide a field to enter the consultation number received but require that we use a third party mechanism. Is there any requirement that they embed the CSDM in to their EMR?

A - No, there is no requirement that EMR vendors embed the CDSM into their systems. National Decision Support Company (NDSC) is ready to integrate with these platforms if they express need.

Q - Our EDs do not collect insurance at check in, only at check out. They are not verifying eligibility either at the ED at the time that they are ordering CT exams on these patients. How will the ED docs even know when to consult AUC because the patient falls under Medicare age?

A - We would suggest these sites look at the patient's age and anyone =>65 have their exam evaluated by a CDSM or have it determined that they met the emergency exception and document that as such. These values (Gcode, outcome or emergency modifier) should be recorded in the EMR.

Q - is the free NCDS option available yet?

A - The National Decision Support Company (NDSC) free tool will be made available to the general market in October of this year, based on the information CMS provides regarding the claims information. In the meantime, the R-SCAN tool provides full access to the qCDSM, and National Decision Support Company (NDSC) will selectively enable access to the tool for specific sites wishing to begin work now.

Q – Can you discuss the priority areas? I am hearing from some CDS vendors that not all advanced imaging need to include the CDS code.

A - The priority clinical areas are for outlier calculations only. AUC consultations will be required for all advanced diagnostic imaging services (CT, MR, PET, nuclear medicine). In the event no AUC exists for the service, a "not applicable" modifier may be used.

Q – Do senior managed care plans have to comply with the Medicare AUC/CDS mandate?

A - No, the AUC mandate applies to Medicare Part B services. Since Medicare Advantage is "Part C", the mandate does not apply.

Q - Will CDS replace the Medicare LCD's?

A - No, the Medicare Local Coverage Determinations (LCDs) and National Coverage Determinations
(NCDs) outlining coverage will remain in place. The AUC consultation program is separate and distinct from coverage. This means that the dx code submitted on the claim must still meet the LCD's medical necessity requirements in order to receive payment, regardless of the CDSM outcome. The ACR and RBMA are having internal discussions on how best to approach the Medicare Administrative Contractors (MACs) about aligning their policies with AUC.

Q - In 2020, the educational and testing year, may imaging providers submit claims for ADI ordered by physicians without consulting AUC via a CDSM?

A - CMS has indicated that the AUC consultation will be mandatory beginning January 1, 2020, however during the one year operations and testing period, there will be no penalties for failure to properly report AUC consultation information. We are awaiting clarification from the Agency on whether this means there will be no penalty when there is no attempt to consult AUC. We expect this clarification by this summer.

Q – How are Urgent Care centers treated for pts who present with an emergent condition?

A - Patients with emergent conditions are exempt no matter what the setting. To qualify an emergency exemption, the patient's condition must meet the definition of an emergency as defined by Section 1867 of the Act - see the appropriate slide in the webinar.

Q – Are the fields for the code going to be in the claim forms?

A - We expect additional information on the specific codes to be submitted from CMS this summer. Generally, the information we have suggests that the G-Code and modified CPT code will use existing fields on the claim form.

Q – How can you layer the LCD onto the CDS??

A - In compliance with the PAMA law, CMS created a process for identifying "qualified provider led entities" whose AUC may be used for the program.

Local Coverage Decisions (LCDs) are developed by the Medicare Administrative Contractors (MAC) using separate processes. While the ACR and RBMA understand the concern about ensuring that "adhere" results are ultimately covered by Medicare, it is not within the scope of the law to align the CDS mechanisms with LCDs rather than the AUC developed by qualified provider led entities.

The ACR and RBMA are conducting internal discussions on how best to approach Medicare Administrative Contractors about aligning coverage policies with AUC.

Q - 2020 implementation only applies to advanced diagnostic imaging (CT, MRI, Nuclear Med), correct? What about general radiology (general & interventional fluoroscopy, radiography)?

A - The program only applies to advanced diagnostic imaging services. There are no current plans to expand the program outside of CT, MR and Nuclear Medicine.

Q – How will the CDSM information get communicated to the imaging providers?

A - The referring physician is responsible for providing the AUC consultation information to the rendering physician as part of the order. How the information is communicated will largely depend upon the capabilities of the systems involved. Some systems will be able to pass it through an electronic interface, while others may require the referring office to manually convey it with the order. With the CareSelect qCDSM, the minimum information needed is the Decision Support Number.

Q - What type of input information will the referring physician need to provide to when using CDS? Is this information different from the current workflow? Do they specifically mention a sign or symptom and a ICD-10 dx code when ordering a study with CDS?

A - The qualified CDS mechanism system will ask for information on the patient's signs and symptoms as well as the test being ordered. AUC are triggered off a Clinical Indication or "Reason For Exam" e.g. a Clinical Question to Answer through Imaging. Based on indication, an appropriateness score will then be generated. The referring physician will need to provide the rendering physician with the name of the CDS mechanism used and whether the result of the consultation was "adhere", "not adhere" or "not applicable". The rendering physician would then place this information, along with the referring physician's NPI, on the radiology claim.

Q – Will the Q code represent the AUC that was used? If so would there be a master list of the groups and who they are using?

A - We expect additional information on the specific codes to be submitted from CMS this summer. The QQ modifier applies during the 2019 voluntary reporting period. The G-code will represent the CDSM while the modifiers will represent the outcome (adhere, did not adhere, or criteria did not apply). We expect a separate G-code to report when an exception applies. These codes will need to be placed on the claim form for payment.

Q - Are there any penalties for not participating in the education and testing period?

A - CMS has indicated that the AUC consultation will be mandatory beginning January 1, 2020, however during the one year operations and testing period, there will be no penalties for failure to properly report AUC consultation information. We are awaiting clarification from the Agency on whether this means there will be no penalty when there is no attempt to consult AUC. We expect this clarification by this summer.

Q - Can you elaborate on the outlier calculation and its implications for the ordering providers? Being able to explain this to the referents may help encourage more enthusiastic adoption and participation from the ordering providers?

A - CMS has not published information about outlier calculation as of yet. We expect this to occur via future Medicare Physician Fee Schedule rulemaking. CMS did indicate that 2020 data will not be used for outlier calculation since it is an "operations and testing period". CMS has indicated that outlier identification will commence in 2023 or 2024.

Q - If an AUC code is not provided by the ordering physician, will there be any way for us to look it up? Similar to how we can find an insurance authorization # if we are unable to reach the ordering provider.

A - Generally speaking, we do not believe you will be able to look up the AUC consultation information if it is not provided to you by the referring physician. However, if using the CareSelect qCDSM, there will be a capability to 'reverse lookup' the consultation information using the DSN.

Q - Just to clarify, which CMS POS numbers are impacted by 2020 testing period (radiologists)? 11,19,22?

A - The regulation applies to all advanced diagnostic Imaging Services furnished under Medicare Part B, and furnished in IDTF, Ambulatory Surgery Centers and the Hospital Setting. The outpatient physician office (11), outpatient hospital, on campus (22), outpatient, off campus (19), and ASC (24). IDTF is not a POS but a specialty code.

Q - The designated person who enters the order and processes the actions for CDS states specifically that it must be “clinical personnel.” Are there specifics outlined as to what credentials have to be held for this ability? Nurse, Tech, MA? specifically not support personnel who are not clinical who are primary staff competing prior authorization currently in most practices. Just seeing if specifics are already set?

A - CMS did not get specific regarding the credentials of the clinical personnel in rulemaking. The 2019 Medicare Physician Fee Schedule Final Rule states, "“When not personally performed by the ordering professional, the consultation with a qualified CDSM may be performed by clinical staff under the direction of the ordering professional...The individual performing the AUC consultation must have sufficient clinical knowledge to interact with the CDSM and communicate with the ordering professional."

Q - Is Epic testing and supporting the CDS-OATS format?

A - Epic is developing against the IHE standard, and has already placed instructions on its user web regarding how to configure Epic to submit the QQ modifier in support of the voluntary period.

Q - If a health system is changing EMR's during 2020, how can they apply for a hardship exception?

A - The hardships exceptions are to be reported on a per test basis. At this time, there is no application process to request to be exempt long term. If a provider believes themselves to be exempt based on the "EHR or CDSM vendor issues" exception, this would be reported each time an advanced diagnostic imaging service is ordered.

Q - Medicare advantage plans already require preauthorization from a third party. Do providers have to do both, an authorization and a CDMS authorization?

A - No, the AUC mandate applies to Medicare Part B services. Since Medicare Advantage is "Part C", the mandate does not apply.

Q- We are doing a big epic upgrade later this year. Can we wait to implement until early 2020 or will all claims starting 1-1-20 without the g code or evidence of CDS having been consulted be rejected?

A - The list of significant hardship exceptions includes "EHR or CDSM vendor issues (including temporary technical problems, installation or upgrades that impede access…)". You may wish to ask CMS if this exception would apply under your circumstances. In addition, we are awaiting clarification from the Agency on whether there will be no penalty when there is no attempt to consult AUC during the operations and testing period. We expect this clarification by this summer.

Q - Do these rules apply to all Ct and MRI or only 8 priority clinical indications?

A- All "advanced diagnostic imaging services", including CT, MR and Nuclear Med. The mandate is not limited to the priority clinical areas.

Q- Will NCDS have a product that radiologists can use on their Provider Portal/website for ordering physicians who don't have an EHR?

A - Yes. Contact National Decision Support Company (NDSC) for more details.

Q - As a physician office, we occasionally provide imaging services for outside physicians (we are an oncology practice). Who is responsible for providing the CDMS data when we submit to outside radiology for reads (and claim ticket) - our physicians or the ordering physicians?

A - The ordering physicians are responsible for conducting the AUC consultation and providing the information to the furnishing physician.

Q - What happens if someone in the ED determines they need an exam that requires CDS but they refuse to document that consultation and simply insist that the study be done? Often ED studies get done before we are ever aware of them. For the 2020 filings, can we simply say "no CDS was done" on our claims. Also, what will ED docs have to do to substantiate the need for an emergent study that bypasses CDS authorization?

A - "To clarify, an authorization number will not be required, but at least initially, a G-code (to indicate which CDSM was used) and modifier (to indicate adherence results) will be required, along with the referring provider's NPI. Specific information on this is expected from CMS this summer.

On the ED question, the exception language states: ""To meet the exception for an emergency medical condition as defined in section 1867(e)(1) of the Act, the clinician only needs to determine that the medical condition manifests itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in: placing the health of the individual (or a woman’s unborn child) in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part.""

In the 2019 Medicare Physician Fee Schedule Final Rule, CMS clarifies that the exception applies even if the ordering physician suspected an emergency medical condition and determined later that the patient did not in fact have an emergency medical condition. If the referring physician suspects an emergency medical condition, that would be conveyed to the rendering physician who would then report the exception on the claim.

CMS also clarified in the 2019 final rule that furnishing professionals are not responsible for confirming the validity of reported exceptions. The Agency will monitor exception reporting."

Q - Can all necessary information (g code) be provided on a hand written order from an outside provide or does CDS compliance need to be communicated electronically?

A - It can be hand written. The information needs to appear on the radiology claim, but CMS does not specify rules on how the information gets from the referring provider to the rendering provider.

Q - Where is the CMS MedLearn AUC Mandate Fact Sheet located (link)?

A – It is located here: Appropriate Use Criteria for Advanced Diagnostic Imaging

It is also located under the “Resources” heading at www.acr.org/cds.

Q - When will the ACR/RBMA tool kit be ready for users?

A - Within the next month. In the meantime, please see www.acr.org/cds for current resources.

Q- Will there be a follow up webinar for understanding what referring physician's might have to answer to get the decision support number?

A - We will consider this input as we plan future webinars.

Q - Is CME available for this webinar?

A - No, CME credits are not available for the webinar.