Clinical Decision Support

• 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. Inpatient exams are also exempted. The U.S. Department of Health and Human Services (HHS) may make limited exceptions for 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)

ACR Statements

• NEW — CMS Further Delays Imaging Appropriate Use Criteria Program (July 2022)
• CMS Extends Educational and Operations Testing Period for AUC Consultation (August 2020)
• ACR Detailed Analysis of CY 2019 MPFS Proposed Rule (July 2018)
• Medicare Releases Final Rule for the Second Year of the Quality Payment Program (Jan. 2018)
• ACR Summary of Medicare Physician Fee Schedule Final Rule for CY 2018 on Appropriate Use Criteria for Advanced Diagnostic Imaging Services (November 2017)

CDS Resources

• AUC Testing Period Claims Processing Requirements Guidance for Providers 
• AUC Change Request Processing Requirements Guidance for MACs
• CMS Appropriate Use Program: Background, Timeline, Rules
• Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging Fact Sheet
• Radiology Support, Communication and Alignment Network (R-SCAN™)
• AUC Navigator — Navigate to qualified provider led entity sites and Appropriate Use Criteria guidance

Webinars on Demand 

These webinars provide important information on the Medicare AUC-based CDS requirement. Please note that CMS has now indefinitely delayed the previously-mandated start date for the CDS program referenced in these webinars.  

• Watch: “ACR/RBMA Webinar: "Implementing Clinical Decision Support in Your Practice" (February 2019)
• Watch: "PAMA AUC Deadline is Firm—Prepare Now for 2020" (December 2018)

• The current testing period has been extended until further notice. This provides additional time for practices to implement clinical decision support systems (CDSMs). During the period, professionals are encouraged to participate in the program - giving CMS an opportunity to make any needed claims processing adjustments before payments are impacted.
  
  CMS may use future Medicare Physician Fee Schedule rulemaking cycles to define the specifics of the outlier policy. Data amassed during the 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 - which is the qCDSM containing the ACR Appropriateness Criteria diagnostic imaging topics - 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, which contains the ACR Appropriateness Criteria diagnostic imaging topics - 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 has granted physicians more than eight years to prepare for implementation (from April 1, 2014, when PAMA became law) 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 500 health systems and 3,000 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. 

• Imaging 3.0 CDS case studies - Gain insights from other practices and departments that have successfully implemented clinical decision support systems.
• Clinical Decision Support for Appropriate Imaging – How Did We Get Here?
• Background and Frequently Asked Questions about Protecting Access to Medicare Act of 2014

• Clinical Decision Support for Appropriate Imaging (set of 4, total 70 minutes)
• Be PAMA AUC Ready: Act Now
• Explaining Imaging Appropriateness to Patients without Clinical Decision Support
• Explaining Imaging Appropriateness to Patients with Clinical Decision Support