The Centers for Medicare and Medicaid Services’ (CMS) Appropriate Use Criteria (AUC) Program is well into the education and operation testing period lasting until the end of 2021, per the extension announced in August 2020. This will require changes to the diagnostic process to include consulting a CMS-qualified Clinical Decision Support Mechanism (CDSM) solution and billing procedures to provide proof of compliance for advanced imaging tests ordered for Medicare-eligible patients.

While inpatients and certain emergency patients are excluded from this change, all other Medicare patients fall into the CDSM category, whether in a hospital setting, group practice setting, or imaging center.

The unique structure of the CMS-defined process presents challenges for the furnishing providers performing the tests since they are financially responsible to code claims based on having received the CDSM certificates from their ordering provider. However, they must rely on the ordering provider to consult a CMS-approved CDSM to generate and forward the actual certificates themselves.

Creating a Win-Win Opportunity for Everyone

The American College of Radiology (ACR) recently published the general consensus among contributing members that referring providers are lacking awareness of the new program and are either unfamiliar or apprehensive. As the furnishing professional, clinicians performing the tests have a financial stake in the outcome, and beginning January 1, 2023, claims submitted without compliance certificates will be rejected.

Proactively engaging your furnishing provider pool may be the most beneficial way to move forward—offering support (and understanding) not only ensures your reimbursement but strengthens your relationships and creates a sense of comradery with your fellow providers. Keep in mind the following points if you are developing an outreach program for your furnishing clinician base:

  • Providers are most likely feeling overwhelmed with absorbing this new information and trying to implement the use of the AUC during the patient visit.
  • They may feel overpowered (or incredulous) by the workflow changes this new program is creating in their practice.
  • Undoubtedly, they feel subjugated or at least frustrated by this CMS-mandated requirement.

Improvements to be Expected

With that in mind, emphasizing the potential positives can go far in helping to alleviate their concerns:

  • CDSM should improve the quality of medical imaging care for Medicare patients.
  • Ordering the right test improves the value of the care provided.
  • This process potentially improves care coordination – once a test is ordered, the rendering provider can send a pre-populated email link where the referring provider can easily fill in the AUC/CDSM information without having to create a whole new workflow.
  • It should enhance health outcomes for patients.
  • CDSM is a MIPS high-weight improvement activity, which means that the ordering providers can earn points for the Improvement Activities category.
  • Potentially, it should prevent some errors and adverse events.
  • CDSM creates an opportunity to improve efficiency in care decisions.
  • And in the end, it will hopefully reduce costs.

By employing a rich library of AUCs sourced from qualified Provider Lead Entities (qPLEs) that are integrated between both furnishing and ordering providers, accurate compliance certificates can be generated seamlessly. Once care has been provided, proper coding justifies the level of service and authenticates the certification compliance to Medicare, and the reimbursement should follow.

Ultimately, the best way to ease the operational requirements may be to consider a Prior Authorization Software integrated with a CDSM Solution that would provide immediate access to both referring/ordering and rendering providers, alleviating some of the administrative burdens. Infinx’s CDSM solution provides furnishing providers the ability to prompt the ordering provider with an email link to do a CDSM consult prepopulated with the patient’s administrative details through our Prior Authorization Software, in the case that they receive an order without an already existing CDSM consult.

Schedule a demo for more information about how our CDSM Solution can help you and your referring provider pool become compliant. And don’t miss an opportunity to further improve your referring doctor’s experience with your practice.

Due to the ongoing pandemic, financial penalties for providing proof of compliance have been postponed until January 1, 2023 pending the pandemic being declared over.