Clinical Decision Support Mechanism (CDSM) Certified

Ensure your advanced imaging orders are approved for Medicare coverage by obtaining certificates of compliance proactively or reactively issued by our CMS-approved intelligent AUC/CDSM solution.


Get Your Patient Access Medicare Workflows Ready To Comply

Requirement to consult AUC with CDSM tool for advanced imaging procedures

Physicians ordering specific advanced imaging tests for Medicare patients will soon need to confirm their treatment decision by consulting appropriate use criteria (“AUC”) with a Center for Medicare Services (“CMS”) approved electronic clinical decision support tool (“CDSM”) pursuant to the Protecting Access to Medicare Act (“PAMA”).

Proof of consult required to get reimbursed by Medicare

Proof of such consult must then be provided to the rendering physician who submits it to Medicare along with the claim for reimbursement after the imaging test is performed. Reimbursements will be withheld if it is determined that the ordering physician did not consult a CDSM tool before ordering the procedure.

Implement early so your staff has time to learn

For those providers with a large base of Medicare patients and high imaging volume, delaying implementation of an approved CDSM tool and adjusting your workflows to include CDSM consults can risk revenue loss at a later date.


Manage CDSM Certifications With Ease

Input patient and service details only once

Streamline the entire patient access workflow, including CDSM consults, from the same platform you input eligibility verification, benefit checks and prior authorization requests.

One dashboard shows all results

A unified dashboard shows results from all patient access activities.

Only platform that manages authorizations for commercial payers and Medicare

We are the only CMS-approved solution on the market that has developed a comprehensive CDSM solution that is integrated with automated eligibility and prior authorization workflows.


High Quality Experience For Referring Physicians

Helpful clinical dashboard

A bi-directional integrated clinical dashboard provides immediate access to current patient information for both furnishing and ordering physicians.

Recommendations for appropriate procedures

Ordering physicians are provided with a high quality clinical decision support experience with an extensive library of AUCs sourced from multiple Qualified Provider Lead Entities (QPLEs) covering priority areas as detailed by CMS like CDI Quality Institute, National Comprehensive Cancer Network and American College of Cardiology.

Full compliance guaranteed

CMS requirements of consultation and reporting, as well as HIPAA, are met. After accepting patient details, a “compliance certificate” is provided for reimbursement.


Simple Workflow

Determines if CDSM consult is required

The referring physician refers to our CMS qualified CDSM portal to determine if CDSM is required based on payer, procedure, and diagnosis details.

Consult is performed

Patient diagnosis and other clinical indications are evaluated against the AUC the a recommendation is provided to the referring physician.

Select the preferred procedure

The referring physician selects the recommended procedure or a different one.

Obtain compliance certificate

They receive a compliance certificate with code starting with CDSM G-code 1018, unique consultation identifier, and adherence modifier, which is sent with the imaging order to furnishing provider, who can then submit it to Medicare along with the claim.


We Take Care Of All CDSM Consults For You

Radiology, orthopedic, and cardiology groups, freestanding imaging centers, and outpatient hospital facilities are in the process of implementing the systems necessary for compliance with the upcoming CMS mandate.

Comprehensive AUC Coverage

Current clinical content with the ability to view AUC evidence for recommendations.

Proactive & Retroactive Compliance

Ability to generate proactive and retroactive compliance certificates if referring physician misses consult during order creation.

One Database

A single repository of all CDSM requests and consult certificates for CMS reporting.

No Integration For Referring Physicians

Ability to support physicians without integration into their EMR/EHR/RIS systems to exchange CDSM certificates.


Compatible With Most EMRs

We offer bi-directional integration with most EHR/EMR/LIS/RIS with API, HL7, FHIR, X12 or EMR developer programs so that your staff can coordinate CDSM consults from your local system Here are some of the systems we integrate or are compatible with.

Infinx - Partner - athenahealth


You Asked, We Answered

Curious if our CDSM solution will meet your needs? Here are the most common questions your peers ask during evaluation.

The new AUC process requires an ordering or referring provider to consult a qualified CDSM, an electronic portal where AUC criteria can be accessed, to determine if the test that’s being ordered adheres to AUC guidelines. Then a Certificate of Compliance is issued to the specialty or rendering provider, ensuring reimbursement for the Medicare claim.

The CDSM is an interactive, electronic tool that communicates AUC information, assists in making the most appropriate treatment decision, and provides the Certificate of Compliance. Notably, if this process is not completed, it is the rendering provider that has revenue at risk even though it is the ordering provider who has the responsibility to comply.

The following advanced imaging services are impacted:

  • computed tomography (CT)
  • positron emission tomography (PET)
  • nuclear medicine, and
  • magnetic resonance imaging (MRI)

Ordering providers must consult with a CMS-qualified CDSM when ordering advanced imaging services for Medicare Part B patients and furnishing providers must report the results of the AUC consultation on the Medicare claim for reimbursement.

Anyone who orders advanced imaging services for Medicare Part B patients — this includes primary care, radiology, cardiology, oncology, sleep medicine, pain medicine, and orthopedics, among other specialties.

Furnishing providers submitting Medicare Part B claims for advanced imaging procedures will not be reimbursed without a proof of CDSM consultation. While the actual certificate is maintained within the patient health record, CPT/HCPCS codes will be required to communicate its existence and consultation outcome.

Three values need to be included:

  1. The CDSM’s G-code (specific to each CMS-approved CDSM software vendor),
  2. The unique consultation identifier which is the proof of consult (similar to an authorization number in prior authorizations), and
  3. The adherence modifier, which indicates whether the procedure selected adheres to the criteria, does not adhere to the criteria, or if the criteria were unavailable.

Yes, if a furnishing provider submits the coded claim that the AUC has been consulted. They will still be reimbursed for the procedure even if it is declared non-adherent or not applicable according to the AUC guidelines.

However, in the future, CMS may require that ordering providers with a high rate of non-adherent procedures will be required to get additional approval such as prior authorizations.

Yes, practitioners conducting advanced imaging services in specialties such as radiology, cardiology, oncology, sleep medicine, orthopedics and others will need access to CMS-qualified software developed in tandem with qualified provider lead entities (qPLEs) that can be integrated with existing EMR/EHR/RIS systems.

Many ordering providers are either unaware of the new mandate or reluctant to participate. It has fallen to rendering providers (and their associated professional organizations) to provide education in many circumstances. We are helping our clients with outreach programs to help educate their referring physicians.

Yes. CMS selected a number of vendors to provide proprietary software that accommodates the AUC and CDSM criteria and Infinx is one of them and has been issued a company specific G code for billing purposes – 1018.

Since furnishing providers are financially liable, the best option is a CDSM Solution that offers the ability for furnishing providers to send a link to generate a CDSM consult to the ordering provider’s email. This will ease the process for both ordering and furnishing providers if a Certificate of Compliance is not provided with an order for testing.


Helpful Resources For Your Team

We create educational materials frequently in the form of virtual office hours, articles, white papers, webinars and podcast episodes which help our clients and peers with common patient access challenges they face. If you would like us to address a specific topic, feel free to reach out to us.


Is Your Organization Prepared For CDSM


Implementing CDSM At Your Organization


Will your Medicare reimbursement survive CMS’s New CDSM mandate?


Four Steps To Implement Successful CDSM Strategy


How Radiologists Can Handle Real-time Changes Outside of Prior Authorization Scope


Infinx CDSM Solution Receives Final CMS Certification

Need To Ramp Up For CDSM Compliance?

Contact us to learn more about how our AI-powered CDSM solution can help your organization comply with the upcoming CMS mandate.