Appropriate Use Criteria (AUC) and Clinical Decision Support Mechanisms (CDSM) are now entering the education and operation testing period lasting until the end of 2020. This will require changes to the diagnostic process (to include consulting AUC) and billing procedures (certificates of adherence) 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 providers performing the tests since they are financially responsible to code claims based on having received the CDSM certificates from their referring provider. However, they are relying on the ordering provider to consult the AUC and then generate and forward the actual certificates themselves via their software through CMS-approved vendors.
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 of the January 1, 2020 deadline for implementation. As the furnishing professional, clinicians performing the tests have a financial stake in the outcome, and beginning January 1, 2021, 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, and
- Undoubtedly, they feel subjugated or at least frustrated by this CMS-mandated requirement.
With that in mind, emphasizing the potential positives can go far in helping to alleviate their concerns:
- CDS 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.
- It should enhance health outcomes for patients.
- CDS 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.
- CDS 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 referring 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.
Schedule a demo for more information about how our CDSM Solution can help you become compliant.