Clinical Decision Support – How Did We Get Here?

What is the Medicare Clinical Decision Support (CDS)/Appropriateness Use Criteria (AUC) requirement?

Effective January 1, 2018, the Protecting Access to Medicare Act (PAMA) will require referring providers to consult AUC before ordering advanced diagnostic imaging services (ADIS) — CT, MR, nuclear medicine and PET — for Medicare patients. Regulations are to be issued by Centers for Medicare and Medicaid Services (CMS) later this year.

What led to appropriateness criteria CDS?

The ACR has long worked to eliminate use of reimbursement cuts to manage imaging utilization in Medicare. Rapid imaging growth in the late 1990s/early 2000s hindered this effort. Much of that growth was appropriate and lowered total health care costs. However, inappropriate or low-value imaging added to the increase.

The Medicare Payment Advisory Committee (MEDPAC) continues to cite overutilization as a major concern. MEDPAC recommended to Congress that CMS consider imposing prior authorization programs in Medicare via for-profit radiology benefits management (RBM) companies. The previous presidential administration included that concept in proposed budgets for a number of years.

ACR offered the appropriate use criteria/clinical decision support solution to ensure appropriate imaging in a way that does not delay necessary care, interfere in doctor-patient decisions, or arbitrarily penalize radiologists via arbitrary cuts.

Use of AUC-based CDS ensures that the patient gets the right scan for the right indication and has been shown to improve quality, reduce low-value scans, and lower imaging costs.

How and why does ACR promote AUC/CDS use?

Imaging utilization continues to be addressed by Medicare and private payers. It is a question of whether it is done via arbitrary cuts and cumbersome prior authorization processes or evidence-based methods. The ACR repeatedly emphasized to referring medical specialties and CMS that CDS/AUC is less burdensome than RBM prior authorization.

The College had its long-standing ACR Appropriateness Criteria® produced digitally into ACR Select for point-of-care access by referring providers via stand-alone CDS or CDS software embedded in a physician’s electronic health record (EHR). ACR Select offers a free stand-alone portal for referring physicians who do not order many ADIS to consult to remain in PAMA compliance.

ACR Select, a digital representation of the ACR Appropriateness Criteria for diagnostic imaging, is a module contained within CareSelect Imaging and can be integrated with all major computerized ordering or EHR systems.

Since PAMA enactment, radiology has not had additional broad reimbursement cuts. In fact, the ACR gained an 80 percent reduction to the professional component Multiple Procedure Payment Reduction (MPPR) — from 25 percent to 5 percent. Despite millions of new Medicare enrollees every day, MEDPAC and scholarly journal data peg imaging as one of the slowest-growing Medicare components .

Why is the CDS solution a better option for radiologists and referring physicians?

The ACR informed Congress and regulatory agencies that AUC consultation should be comprehensive (for ADIS) and be performed by referring providers to optimize ADIS use and act as an educational tool to referring providers

Modifying this requirement (e.g., for limited clinical indications, for only selected patients or by radiology facilities assuming part or all of that duty) will create confusion, prolong implementation and decrease the value of the CDS process.

Imaging providers will not be competitively disadvantaged by this federal requirement:

  • No rendering provider can receive Medicare payment for ADIS if the referring provider does not attach a physician identifier likely to be termed a “decision support number (DSN)” to the referral
  • All radiology providers may refuse Medicare referrals without this documentation
  • 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 to which providers can shift this Medicare imaging
  • These factors should quickly result in integration of CDS in referring practices  

Imaging providers cannot assume the administrative duties of AUC as they could for prior authorization. The differences between prior authorization and CDS/AUC are:

  • Prior authorization is binary (Yes or No). There is no educational component to the provider, as authorization is routinely done by office personnel with no interaction with that provider.
  • There is no potential for the referring provider to use that process to discuss with the radiologist and/or patient why a given imaging examination was the optimal choice (if imaging is indicated)

How and why can radiologists promote AUC/CDS use?

By promoting CDS/AUC, radiology can position itself as a resource to hospital and health system administrators. This is a vital opportunity as medicine transitions from volume- to value-based care.

CMS has named the ACR a “qualified Provider-Led Entity” (qPLE), approved to provide AUC under the Medicare Appropriate Use Criteria program for advanced diagnostic imaging. As such, providers can consult ACR Appropriateness Criteria to fulfill these PAMA requirements.

ACR Select, a digital representation of the ACR Appropriateness Criteria for diagnostic imaging, is a module contained within CareSelect Imaging and can be integrated with all major computerized ordering or EHR systems.

To help referring providers and radiologists become familiar with appropriateness criteria-based clinical decision support systems, the ACR is administering the CMS-funded Radiology Support, Communication and Alignment Network (R-SCAN™). R-SCAN is a collaborative action plan that brings radiologists and referring clinicians together to improve imaging appropriateness (without payment implications) and get CME Credit and recognition for ABR maintenance of certification Part 4 Credit.