Preparing for the 2020 CMS Mandate for Clinical Decision Support

By Infinx
October 8, 2019

As the January 1, 2020 mandatory implementation date approaches, radiology and cardiology 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. This is part of the “Protecting Access to Medicare Act” (PAMA) passed by Congress in 2014 and is designed to improve diagnostic accuracy and quality of care 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. It’s mandated 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 that will greatly enhance the clinical decision experience.

CDSM and Specialty Practices

Looking through the practice lens of radiology and cardiology, 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 needless 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.

Whether seeking a modular system that integrates with an existing prior approval software or a stand-alone 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 clinical dashboard that provides immediate access to current patient information for both furnishing and ordering physicians
  • 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 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 the 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 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 and Reimbursement for Radiology

The CMS has announced that there will be corresponding HCPCS G Codes provided that will be used to modify the CPT procedure codes. Until they are released, 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. The “compliance certificate” then becomes part of the patient’s EHR and must be transmitted to the referring provider to supplement their billing and claim submission process.

At face value, the new requirements seem overly burdensome, but it will provide valuable data to help demonstrate utilization management as future healthcare criteria evolve through the CMS. AUC and CDSM can ultimately reduce the administrative burden on all providers and significantly strengthen the patient experience.

Ultimately, the best way to ease the operational requirements may be to consider a Prior Authorization Software, that would provide immediate access to both referring/ordering and rendering providers, alleviating some of the administrative burdens.

Contact Infinx for more information about how our CDSM Module can help you become compliant.

About the Author



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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