Q - What are the risks and/or penalties for not implementing CDS come January of 2020?
A - The reporting and testing period runs Jan. 1, 2020 – Dec. 31, 2020. Payment is not at risk during this time due to shortcomings or mistakes in the claims process. We do not know all of the data required to be incorporated on claims during this period. Claims may require some attestation of a consultation to make providers ready for mandatory use. That would be clarified in future rulemaking.
However, there must be an effort made to use the AUC claims during this time. Jan. 1, 2021 is when the mandatory program goes live. After that date, payment may be denied for failure to verify that the AUC process was satisfactorily used.
Q - How will the CDS consultation be communicated from the ordering provider to the furnishing provider for claims reporting purposes?
A - Transmittal method of orders to furnishing providers remains the same as in use in today - for example: electronic message, faxed order, or within a healthcare institution – EHR automated functions.
If the exam is ordered within the EHR, and furnished within the same healthcare system, generation and transmittal of information associated with the consultation to the claims and revenues cycle process is generally handled automatically. Many organizations who have integrated decision support into their electronic medical record application are already submitting the q-modifier, the optional modifier to the CPT code to indicate that a consultation has taken place of a mechanism.
If in an ambulatory environment with access to an EHR with an integrated system, there is an HL-7 standard developed to convey this information in electronic orders. If you are a furnishing site, be sure that your systems used to furnish exams are capable to extract this information and put it into the right place inside of your information system to reflect on the claim.
Also, there are free CDS tools that are available. For example, the NDSC free tool produces information, and that CMS has instructed the mechanism producers that offer web access points to also include this information. Whereby, after a consultation, a printable form is produced that contains the necessary CPT code modifiers and G-codes, that can be printed or faxed along with the order to the furnishing site.
There are a number of ways that this information can be conveyed by a primary care provider in an ambulatory setting that does not have access to an integrated EHR system. Using the web tool, the final step of their decision support interaction will be a printable or e-mailable form that contains the necessary data on it for a payable claim.
Q - How should emergency medicine providers document exceptions to applying decision support? Is the definition of conditions that qualify for exemption the same as in EMTALA?
A - Emergency medical condition is a defined term under the EMTALA Act. The exclusion applies to patients that have emergency medical conditions, regardless of care setting. That exemption would need to be communicated to the subsequent furnishing provider.
With respect to documenting that exclusion, it depends on the method in which the order is being placed. If you have emergency medical conditions episode within the electronic medical record, most healthcare organizations have workflows in place to allow treatment of that patient before any of the electronic medical interactions occur.
In many cases where CDS is implemented within the electronic medical record, NDSC does utilize (and perhaps other vendors as well) the emergency services index that many EHRs provide where they have a high acuity ESI as an example in that case where we do not trigger decision support and automatically apply the exclusion.
Q - How do you handle outside orders made outside of CDS, but the person entering the order gets the information when they do enter the order? Do you call the ordering person and tell them the finding?
A - The law is clear that referring providers cannot access decision support on behalf of the ordering providers for the purposes of payment. If a scheduler, as an example, receives an order for a Medicare patient for an advanced imaging order, and there is no consultation information associated with that, that scheduler can make that ordering provider aware of the access to either the free tool or the decision support tools within their application depending on their environment. There could even be an interactive educational session teaching the first time or the second time they need to access decision support.
There are a number of tools that the ACR provides to help radiology practices educate referring providers and staff in advance of the Medicare AUC mandate. We urge radiology providers to use these tools to help their referring providers become familiar with CDS before January 1, 2020.
Q - How do I generate an appropriateness score for outside orders that don’t come via CDS? If the outside provider does not generate a score, does that affect our hospital’s compliance?
A - The referring provider must consult decision support or report an exclusion. If the furnishing provider receives an order for a Medicare advanced imaging study that does not contain this consultation information, the service that they furnish will not be paid. The only way to make that a payable claim would be to have consultation data. The only people that can generate that consultation data are the ordering providers or their clinical staff operating under their supervision.
Q - What might an implementation of CDS look like at a 100 percent outpatient radiology group?
A - At a 100 percent outpatient radiology group, first aspect of implementation is educating referring providers – as advanced imaging orders for Medicare patients require/trigger decision support.
Engage those referring providers. Make them aware of the free tool, introduce them to organizations that offer tools for consultation. On the furnishing side, ensure that your practice is working with your practice management system, and the vendor of that system, to ensure that it is capable to receive the HL-7 information from those sites that might choose to embed that information into the electronic order - or is capable to actually record the consultation data, which would be the modifiers and the G-codes, as specified in the CMS transmittal. Ensure that that data gets through the revenue cycle to your billing company. The implementation would be between the practice management system receiving the data and the workflows associated with scheduling, along with the dialogue with the billing company to ensure that they are aware of the requirement and that the data they need to generate a claim for your payment is generated.
Q - Do the CDS or AUC requirements apply solely to Medicare or also to Medicare Advantage Plans?
A - The requirement applies solely to Medicare – not to Medicare Advantage plans. For example, for critical access hospitals who might bill under the optional payment method, the program does not apply. Actually critical access hospitals, just as a good example, are not counted as applicable settings. Exams furnished within the critical access environment would not be subject to the consultation requirement. The best way to understand if a consultation is a requirement is to work back from the payment method elected. So, if it is Medicare Part B advanced imaging, and it’s paid under that payment model, whether it’s a professional or a technical service, the consultation is required. But programs like Medicare Advantage or other risk-based payment programs do not have the consultation requirement.
Q - Can a radiologist change an order after the order has come through the CDS, (e.g., no contrast or with contrast)? How does that affect the process?
A - Within Medicare payment models, there is a limited number of things that a furnishing provider can do to modify the order before a new order is required. Factors like contrast and laterality, are within the scope of the furnishing provider to change. However, other things, such as the actual service and the protocol are not.
There are specific rules that govern the number of changes that the furnishing provider might make to a Medicare Part B order. Whatever the consultation, information reported to you by that ordering provider must be entered on the claim, independent of whether or not a revision would make the order more appropriate.
Q - How do I handle providers that continually place orders with low AUC scores?
A - If a provider continues to order studies that are inappropriate on the AUC scale, the program may identify those physicians as “outliers.” These providers will ultimately be required to go through prior authorization for such orders. The start date for such action has yet to be finalized. However, even though a provider may be ordering an inappropriate or less-appropriate exam, there is no “hard stop” that precludes them from ordering such exams.
When an order reaches the radiology facility, and a radiologist decides the exam may not be appropriate, that is when a consultation could occur with the ordering provider. Having transparent electronic appropriate use criteria makes those conversations easier.
Q - How do you get independent providers to utilize decision support?
Introduce your referring physicians to the R-SCAN platform and urge them to take part in the program with you. R-SCAN has educational material to easily promotes these conversations.