2020 Countdown: Are You Ready CDSM Ready?

By Infinx
November 27, 2019

With January 2020 almost here, it’s time to assess your readiness for CDSM implementation!  As the mandatory date approaches, radiology, cardiology, and orthopedics practices, freestanding imaging centers, and outpatient hospital facilities are weighing their readiness and implementing the systems necessary for compliance with the CMS Medicare rules governing the Appropriate Use Criteria (AUC) Program.  As part of the “Protecting Access to Medicare Act” (PAMA) passed by Congress in 2014, this program is designed to improve diagnostic accuracy when ordering advanced imaging services while reducing unnecessary testing for Medicare patients.

The AUC Program is focused on supporting referring providers when ordering advanced diagnostic and interventional testing services to include MRI, CT, Nuclear Medicine, and PET. CMS is mandating that when ordering these advanced imaging services, the referring provider or their designee will be required to consult a Clinical Decision Support Mechanism (CDSM), an interactive, electronic portal where they can access AUC and greatly enhance the clinical decision process.

CDSM and Specialty Practices

Looking through the practice lens of radiology, cardiology, and orthopedics, the AUC Program and CDSM were conceived as a process that would complement and elevate the referring provider’s diagnostic practice, strengthen the Medicare patient experience, and reduce unnecessary advanced image testing. The requirement impacts all physicians, APP, and facilities billing Part B Services to Medicare.  Note that exclusions are being made for emergency patient encounters, inpatient services billed through Part A, and ordering professionals with significant hardship, such as rural proximity to services.

When reviewing and evaluating a comprehensive CDSM package from the CMS published list of approved vendors, consider a partner that offers these valuable components:

  • A comprehensive and up-to-date library of AUC’s sourced from multiple Qualified Provider Lead Entities (qPLE’s)
  • A bi-directional, integrated clinical dashboard that provides immediate access to current patient information for both furnishing and referring providers
  • Coverage of all priority clinical areas as detailed by the CMS, including coronary artery disease (suspected or diagnosed), suspected pulmonary embolism, headache, hip pain, low back pain, shoulder pain (to include suspected rotator cuff injury), cancer of the lung (primary or metastatic, suspected or diagnosed)
  • Ability to support referring providers within their EHR/EMR systems
  • Ability to generate compliance certificates required for reimbursement
  • A qPLE that meets all security requirements and HIPAA compliance standards

Are Referring Providers Prepared?

The American College of Radiology (ACR) has recently noted the general consensus among contributing members is that referring providers are lacking awareness of the new program and are either unfamiliar or apprehensive of the January 1, 2020 deadline for implementation. As the furnishing professional, you have a financial stake in the outcome, and beginning January 1, 2021, claims submitted without compliance certificates will be rejected.

Similarly, the American College of Cardiology (ACC) has released its “Heart of Health” Policy Statement noting that CMS has released the proposed 2020 Medicare Physician Fee Schedule (PFS), and there is no change to the mandate for CDMS. The ACC notes that CMS is issuing a virtually flat conversion rate factor of $36.09 from $36.04 in 2019, which makes complying with the CDMS mandate even more critical since denials must be avoided to meet future reimbursement pressure challenges.

This has created a somewhat awkward situation that may best be resolved by radiologists, orthopedists, and cardiologists partnering with their hospital colleagues to spearhead an awareness campaign that educates primary care providers in the benefits brought by AUC and CDSM. While this is currently mandated for Medicare patients only, be assured that third-party insurance carriers will have a keen eye on the roll-out and implementation in 2020.

Medicare Coding for Advanced Imaging

On July 26, 2019, the CMS announced the official HCPCS Modifiers and G Codes to be used to modify the CPT procedure codes.  They will be effective on January 1, 2020.  Until then, HCPCS modifier QQ (Ordering Professional Consulted a Qualified Clinical Decision Support Mechanism for this Service, and the Related Data was Provided to the Furnishing Professional) should be reported on both the facility and the professional claim.

New HCPCS Modifiers

  • MA – Ordering professional is not required to consult a clinical decision support mechanism due to service being rendered to a patient with a suspected or confirmed emergency medical condition
  • MB – Ordering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of insufficient internet access
  • MC – Ordering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of electronic health record or clinical decision support mechanism vendor issues
  • MD – Ordering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of extreme and uncontrollable circumstances
  • ME – The order for this service adheres to the appropriate use criteria in the clinical decision support mechanism consulted by the ordering professional
  • MF – The order for this service does not adhere to the appropriate use criteria in the qualified clinical decision support mechanism consulted by the ordering professional
  • MG – The order for this service does not have appropriate use criteria in the clinical decision support mechanism consulted by the ordering professional
  • MH – Unknown if ordering professional consulted a clinical decision support mechanism for this service, related information was not provided to the furnishing professional or provider
  • QQ – Ordering professional consulted a qualified clinical decision support mechanism for this service and the related data was provided to the furnishing professional (effective date: 7/1/18)

New G Codes 

  • G1000 Clinical Decision Support Mechanism Applied Pathways, as defined by the Medicare Appropriate Use Criteria Program
  • G1001 Clinical Decision Support Mechanism eviCore, as defined by the Medicare Appropriate Use Criteria Program
  • G1002 Clinical Decision Support Mechanism MedCurrent, as defined by the Medicare Appropriate Use Criteria Program
  • G1003 Clinical Decision Support Mechanism Medicalis, as defined by the Medicare Appropriate Use Criteria Program
  • G1004 Clinical Decision Support Mechanism National Decision Support Company, as defined by the Medicare Appropriate Use Criteria Program
  • G1005 Clinical Decision Support Mechanism National Imaging Associates, as defined by the Medicare Appropriate Use Criteria Program
  • G1006 Clinical Decision Support Mechanism Test Appropriate, as defined by the Medicare Appropriate Use Criteria Program
  • G1007 Clinical Decision Support Mechanism AIM Specialty Health, as defined by the Medicare Appropriate Use Criteria Program
  • G1008 Clinical Decision Support Mechanism Cranberry Peak, as defined by the Medicare Appropriate Use Criteria Program
  • G1009 Clinical Decision Support Mechanism Sage Health Management Solutions, as defined by the Medicare Appropriate Use Criteria Program
  • G1010 Clinical Decision Support Mechanism Stanson, as defined by the Medicare Appropriate Use Criteria Program
  • G1011 Clinical Decision Support Mechanism, qualified tool not otherwise specified, as defined by the Medicare Appropriate Use Criteria Program

At face value, the new requirements may seem overly burdensome for radiology, cardiology, and orthopedic practices who will be obligated to submit a compliance certificate with each Medicare claim, but are not responsible for generating the actual certificate.  The intent is that this process will provide valuable data to help demonstrate better utilization management as future healthcare criteria evolve through the CMS.

Ultimately, the best way to ease the operational requirements would be to implement a CMS-approved CDSM Module, that would provide immediate access to both referring/ordering and rendering providers, alleviating some of the administrative burdens.

Schedule a demo with Infinx for more information about how our CDSM Module can help you become compliant.

 

 

About the Author

Infinx

Infinx

Infinx provides innovative and scalable payment lifecycle solutions for healthcare practices. Combining an intelligent, cloud-based platform driven by AI with our trained and certified coding and billing specialists, we help clients realize revenue, enabling them to shift focus from administrative details to billable patient care.

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