Recognizing the challenges brought by the new Clinical Decision Support Mechanism (CDSM), the Centers for Medicare and Medicaid Services (CMS) extended the mandatory implementation date to January 1, 2023.1 This extension is intended to give both furnishing and ordering providers ample time to negotiate the technological and workflow challenges before there is a monetary impact.
With the 2020 training and education period fully underway, healthcare providers are using Appropriate Use Criteria (AUC) to generate
certificates of compliance through a CDSM module for advanced imaging tests performed on Medicare patients. By using a CMS- approved vendor, furnishing providers can harness AI-driven technology to generate proactive and reactive certificates in support of ordering providers that ensure reimbursement once the 2023 mandatory implementation date arrives.
Assessing the New Guidelines
The CMS rules governing the AUC Program are part of the “Protecting Access to Medicare Act” (PAMA)2 passed by Congress in 2014. The AUC program is designed to improve diagnostic accuracy when ordering advanced imaging services while reducing unnecessary testing for Medicare patients.
The AUC program supports ordering 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 ordering provider or their designee will be required to consult a CDSM. In this interactive, electronic portal where they can access AUC and greatly enhance the clinical decision process. With 2020 well underway, it’s time to assess readiness for the 2023 mandatory CDSM implementation! As the January 2023 date approaches, practices that perform advanced imaging testing, including radiology, cardiology, orthopedics practices, freestanding imaging centers, and outpatient hospital facilities, weigh their readiness and implement the systems necessary for compliance.
Defining the Appropriate Use Criteria Program and Its Components
As defined by the American Medical Association (AMA), “CDSM is an interactive, electronic tool for use by clinicians that communicates AUC information to the user and assists them in making the most appropriate treatment decision for a patient’s specific clinical condition. They may be modules within or available through certified electronic health record (EHR) technology”.
In supporting ordering providers, AUC specifies when it is appropriate to use a particular advanced imaging procedure. An “appropriate” procedure is one where the expected health benefits exceed the expected risks by a wide margin. Further quoting the AMA, “Often, sound data is not available or does not provide evidence that is detailed enough to apply to the full range of patients seen in everyday clinical practice. Nevertheless, physicians must make daily decisions about when to use or not use a particular procedure. AUCs facilitate these decisions by combining the best available scientific evidence with the collective judgment of physicians to determine the appropriateness of performing a procedure”.
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 ordering 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 made for emergency patient encounters, inpatient services billed through Part A, and ordering professionals with significant hardship, such as rural proximity or lack of internet connectivity or services.
Important Considerations when Selecting from the List of CMS-Approved Vendors
When reviewing and evaluating a comprehensive CDSM package from the CMS published list of approved vendors,6 practices should 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 (qPLEs)
- A bi-directional, integrated 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 ordering providers within their EHR/EMR systems
- Ability to generate compliance certificates required for reimbursement either from a proactive or reactive stance • A qPLE that meets all security requirements and HIPAA compliance standards
Special Consideration: Orthopedic and cardiology practices are in the unique situation of potentially being both a furnishing (if so equipped) and ordering provider depending on the situation. For example, they may provide advanced imaging testing within their practice for patients referred by an ordering provider and may also refer a patient to a radiologist for testing that they cannot do within their purview.