ACR Bulletin

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Critical Support

Teaming up with referring providers can preserve reimbursement and boost quality of care.
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CDS has the potential to create more of a dialogue between radiologists and ordering physicians about what constitutes appropriate imaging.

—Timothy Huber, MD
November 15, 2018

To ensure success under PAMA, radiologists need to take the lead in educating physicians and other referring providers on the importance of adopting an approved CDS in their workflow.

“CDS has the potential to create more of a dialogue between radiologists and ordering physicians about what constitutes appropriate imaging,” says Timothy Huber, MD, vascular and IR fellow at the University of Virginia. “That hasn’t been happening as much as it probably should be, and we need to make sure we’re doing the right study on the right patient at the right time.”

The dialogue is critical not only to quality of care, but also to radiologists’ compensation. It behooves radiologists to encourage referrers who order advanced diagnostic imaging services — in outpatient and ER settings for non-life-threatening visits — to take advantage of CMS’s voluntary reporting period for adopting Appropriate Use Criteria (AUC).

Even so, more than half of radiologists surveyed have yet to begin implementing CDS to provide evidence of AUC consultation when placing orders. When CMS begins its first-year testing period for documenting AUC for Medicare patients in 2020, some form of CDS should be in place to protect radiologists’ payments for advanced imaging studies. Ultimately, CMS will not pay radiologists for studies that were not ordered by referring physicians who have consulted a CDS system.

While there won’t be any penalties that first year for referring physicians who incorrectly report their use of AUC, radiologists would be wise to preemptively facilitate CDS with referrers to avoid reimbursement cuts or claims denials by radiology benefits managers (RBMs). In fact, it is the radiologist, not the referring physician, who will be penalized when a referring physician fails to consult a CDS system.


CDS gives providers a tool through which to offer recommendations for the best imaging study for a given indication. Aside from it being mandatory under PAMA, the integration of CDS has the potential to lower total costs, result in shorter lengths of stay for patients, lower the probability of 30-day readmissions for patients, and reduce the number of complications when compared to patient encounters where embedded CDS alerts were not used.

Studies have shown that a commercially available CDS tool integrated into the EHR has resulted in significant improvements in imaging study appropriateness scores.

CDS also has the potential to protect payments for radiology services by reducing the number of claims denials. According to Huber, “It could replace RBMs or even prior authorization in some circles.”


Beyond fair reimbursement and patient satisfaction, putting CDS into practice is an opportunity for radiologists to have their voices heard. “Referring providers and radiologists should work together so that decisions about the appropriateness of studies aren’t being made in silos,” says Melissa M. Chen, MD, clinical neuroradiologist in the department of diagnostic radiology at the University of Texas MD Anderson Cancer Center.

Using CDS to show AUC will strengthen communication between radiologists and ordering clinicians, Chen says. The system could eliminate unnecessary phone calls and a lot of basic questions, opening channels for a more sophisticated conversation.“With CDS, we could give more valuable input,” she says. “We could triage questions pertaining to more personalized issues around a patient and their clinical condition. These are the questions that should be asked instead of the incorrect imaging studies being performed.”

When Chen was at the Baylor College of Medicine, she was part of an effort to eliminate unnecessary imaging for lower back pain. She and her colleague, Christie M. Malayil Lincoln, MD, worked with ordering clinicians, coaching them on imaging appropriateness. And those clinics, in turn, made recommendations to other clinics whose physicians may have been ordering studies incorrectly.

This type of engagement with referrers is the only way to get them on board with CDS. “Come out of the reading room and engage,” Huber says. “Talk to the physicians who are going to be ordering the studies. You have to do that on the front end to really get them to buy into it. Even then, not everyone will be willing to adopt; people are always resistant to change, and doctors are no exception.”

Residents have responded more to feedback from decision support systems than attending physicians, Huber notes, and will likely be more willing to accept feedback regarding the ACR Appropriateness Criteria® (AC). “This suggests that the next generation of physicians will be more willing to engage with the technology and take the advice of the CDS system.”

There’s no time to waste when reaching out to other physicians across departments to promote the use of CDS. An institution-wide health IT initiative often takes years to implement successfully. For the referring doctors you work with, “explain what you’re doing now, and what you’re trying to do down the road with the new software,” Huber says. “Give them the rationale behind it and explain how they can use CDS most effectively.”

For instance, CareSelect® Imaging, the digital representation of the AC for diagnostic imaging that can be integrated into most EHRs, is one tool available to physicians. “The ACR has been very forward-thinking with the development of CareSelect,” Huber says. “It basically takes the College’s AC, which are compiled from an expert panel’s guidelines for imaging, and delivers that knowledge and information to the ordering doctors at the time of order entry.”

“Different radiologists within a group should volunteer to take turns visiting different departments to educate ordering physicians,” Huber says. Tell referrers you want to help with a smooth CDS transition and that you are willing to meet with administration to make sure everyone is on board, he adds.


“Don’t be a stranger,” Chen says. Referring physicians sometimes think radiologists are too busy for them to pop in and ask a question, she says, and the onus is on radiologists to address this.

“A lot of people don’t even know where the radiology department is,” Chen says. There can be resistance, too, about taking the time to talk to people. “That doesn’t make sense,” she says. “We participate in a team, and they are referring patients to you. How are you going to potentially grow your practice if you don’t develop a relationship with these people?”

There are many ways to foster a relationship. Start by choosing the right CDS vendor and mechanism — one that best aligns with the healthcare team. The size and scope of CDS tools matter. Don’t be afraid to make inquiries of radiology leaders at other hospitals or health systems about how they have successfully integrated CDS into their physicians’ workflow.

Some radiology teams have had positive results from presenting information on CDS at healthcare conferences. It’s always useful to solicit feedback from participants after training — either in person or through online surveys. A good rule of thumb is to find out what will work best and what people are willing to spend to accomplish integration.


“As a specialty, if we can take the reins and target inappropriate imaging, we’ll be in a better position down the road to negotiate with payers like CMS and the insurance companies,” Huber says.

Continued spending on inappropriate imaging studies will result in radiology continuing to be targeted by payers, Huber believes. “If we don’t get ahead of the problem now, we will continue to see cuts to imaging reimbursement.”

With the current legislation, practices are slated to incur costs down the road if CDS isn’t implemented, Huber adds. The financial benefit in the long run is likely to outweigh the cost of implementing CDS. “It’s kind of like implementing an EHR at a small practice group,” he says. “The upfront costs can be expensive, but this is where the field is heading.”

ACR recommends that radiologists direct referring physicians to CMS’s website to explain upcoming requirements and available options. Preliminary findings have shown that CDS can improve outcomes, but study authors note that more research is needed because many groups have yet to implement CDS.

“CDS will make it easier to defend growth in imaging,” Huber says. “It’s only going to keep growing, and we can strengthen our position now to secure our place in the evolving healthcare marketplace with evidence of what is medically appropriate.”

Author Chad Hudnall  Senior writer, ACR Press