Are You Ready for CDSM in 2022 (or Possibly 2023)?

UPDATE: CMS proposed the following on July 13, 2021, “CMS is proposing to begin the payment penalty phase of the AUC program on the later of January 1, 2023, or the January 1 that follows the declared end of the PHE for COVID-19. This flexible effective date is intended to take into account the impact that the PHE for COVID-19 has had and may continue to have on practitioners, providers and beneficiaries. Currently, the payment penalty phase of the AUC program is set to begin January 1, 2023.”

With the Centers for Medicare and Medicaid Services (CMS) recently extending the mandatory implementation date to January 2023, it’s time to assess your readiness for Clinical Decision Support Mechanism (CDSM) implementation! 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.

In its letter dated August 17, 2020, the American Medical Association (AMA) stated that the additional time extended was to help prepare for mandatory implementation and “the technical and workflow challenges brought with the CDSM 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 CDSM, an interactive, electronic portal where they can access AUC and greatly enhance the clinical decision process.

CMS has an approved list of vendors, of which Infinx is a qualified vendor. By using Infinx’s CDSM Solution, advanced automation would process certificates of compliance for CDSM that will ensure payment from Medicare after the mandatory implementation date of January 1, 2023. The Infinx CDSM Solution is the only CDSM software that you can manage your CDSM and prior authorization claims using one platform.

The Infinx CDSM Solution is fully integrated with the Infinx Prior Authorization Software, which allows consults to be approached from a proactive or reactive stance. This means that certificates of compliance can be initiated by a group reactively if the patient is referred without the appropriate CDSM approval.

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 internet service.

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 ordering 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 ordering providers are lacking awareness of the new program and are still either unfamiliar or apprehensive of the deadline for implementation. As the furnishing professional, you have a financial stake in the outcome, and beginning January 1, 2023, 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 2021 and beyond.

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 were effective on January 1, 2020.

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
• G1018 Clinical Decision Support Mechanism Infinx CDSM, 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 qualified CMS-approved CDSM Solution, that would provide immediate access to both referring/ordering and rendering providers, alleviating some of the administrative burdens. Infinx’s CDSM Solution can be used both proactively and reactively ensuring that ordering providers can be looped in when necessary and supported through the process.

Request a demo with Infinx for more information about how our CDSM Solution can help you maintain compliance and ensure Medicare reimbursement.