Medicare reimbursement for outpatient advanced imaging is about to get more complicated —Are you ready for the new CMS Mandate taking effect on January 1, 2023!

Beginning on January 1, 2023, the CMS Mandate governing the new Clinical Decision Support Mechanism (CDSM) and the Appropriate Use Criteria (AUC) Program will officially start. Currently in a two-year education phase, the AUC program was designed to assist physicians who order advanced imaging testing or procedures. The new CMS Mandate is part of the “Protecting Access to Medicare Act” (PAMA) passed by Congress in 2014.

Intended to reduce unnecessary imaging by assisting referring providers in the appropriate use of diagnostic testing, this new program would deny reimbursement to the rendering providers if a certificate of consultation is not obtained and denoted on their claims to Medicare. This could result in significant loss of revenue not only for radiology practices, but also cardiology and orthopedic practices, as well as outpatient hospital facilities and imaging centers that see Medicare Part B patients.

It’s important to note that inpatient services (billing for Medicare Part A), emergency patients, and ordering physicians with significant hardship, such as proximity to internet services, have been excluded from the mandate.

What is CDSM and how will it affect Medicare reimbursement?

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.

What tests fall under the new mandate?

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.

Which specialties are impacted by this?

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.

What happens if a Certificate of Compliance isn’t obtained?

Starting January 2023, 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.

What must be included in the furnishing provider’s advanced imaging claim to Medicare and CDSM compliance certificate?

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.

A list of G-codes and modifiers is available here.

Will a procedure still be reimbursed if it does not adhere to the Appropriate Use Criteria?

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.

Can a CDSM electronic portal integrate with existing records systems?

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.

Where can I access a list of CMS approved CDSM software solutions?

CMS selected a number of vendors to provide proprietary software that accommodates the AUC and CDSM criteria. Listed here, every approved vendor has been issued a company-specific G Code for billing purposes.

Are ordering physicians aware of the CDSM mandate?

According to the American College of Radiology (ACR), 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.

How can a furnishing provider enlist the ordering provider’s cooperation?

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.

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About Navaneeth Nair

Navaneeth Nair is Chief Product Officer at Infinx Healthcare which provides leading-edge AI-assisted end-to-end solutions across the payment lifecycle, including patient access, prior authorization, and revenue optimization. Navaneeth has over 20 years of experience in healthcare, where he has specialized in leading large-scale technology product and solutions developments.

Media Contact:

Navaneeth Nair
Infinx Healthcare

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.