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Imaging CDS: What you need to know from Medicare's most recent proposals

July 24, 2017

    CMS recently released its proposed rule on the Medicare Physician Fee Schedule (MPFS), which dictates clinician payments each year.

    Some of the biggest news for radiology providers concerns the imaging clinical decision support (CDS) mandate, or Medicare Appropriate Use Criteria (AUC) program. Most notably, implementation of the program is delayed until 2019. We've analyzed the latest proposals and provided guidance for how programs can set themselves up for CDS success. 

    A brief recap on CDS

    In the Protecting Access to Medicare Act (PAMA) of 2014, Congress included a mandate that ordering providers consult appropriate use criteria via electronic CDS when ordering outpatient advanced imaging exams for Medicare patients. Furnishing providers—most commonly radiologists and imaging programs—must document that consultation for reimbursement.

    The legislation required CMS to provide implementation details around four key components of the program:

    For more information on the previously finalized components and priority clinical areas, read our analysis of the 2017 final rule.

    Four key takeaways from recent CMS proposals

    1. CMS wants to delay the CDS implementation deadline until Jan. 1, 2019

    The agency proposed to move the provider deadline for CDS from Jan. 1, 2018 to Jan. 1, 2019, with the possibility of a voluntary reporting period beginning in July 2018. CMS has also proposed using 2019 as an "educational and operations testing period." During this time, ordering providers would be expected to consult AUC and furnishing providers would be expected to confirm consultation on claims submitted to Medicare. To encourage providers to engage with CDS without fear of immediate reimbursement cuts, CMS proposes to continue paying all claims in 2019. Claims denials and reimbursement penalties would begin Jan. 1, 2020.

    Timeline for clinical decision support
    Based on MPFS proposed rule for 2018

    Timeline for clinical decision support

    Guidance for providers: Rather than halting CDS work, organizations should use the educational period to ensure they are set to collect full Medicare reimbursement come 2020. Organizations should use the additional year to improve the system through comprehensive testing and should continue training ordering providers on the importance of CDS adherence. Use our tools and resources to prime ordering providers, assemble a CDS team, and educate all stakeholders.

    2. Clinical Decision Support Mechanisms (CDSMs) have been approved

    Much of last year's MPFS rule focused on requirements and approval processes for CDSMs. This summer, the agency released its first list of approved mechanisms. Until the provider deadline, CMS is allowing two different qualification options for CDSMs:

    1. Full qualification: CDSM met all requirements by the March 1, 2017 application deadline; and

    2. Preliminary qualification: CDSM met most, but not all, requirements by application deadline; CDSM demonstrates a clear timeline for when and how it will meet all requirements by the provider deadline. CDSMs granted preliminary qualification status must meet all requirements by 2019 or the CDSM will be de-qualified and must notify all providers of this de-qualification status.

    Qualified CDSMs

    *Free tool available.

    Guidance for providers: Be informed about CDS vendors and their approval status. For those with preliminary approval, ask what requirements they do not yet meet and request an estimated delivery date of that requirement.

    3. Providers would be able to document CDS consultation with new HCPCS modifiers and G-codes

    While the ordering provider must consult CDS, the furnishing provider is responsible for reporting that this consultation took place. CMS will use imaging claims to track compliance. The agency proposed three items that must be reported on all imaging claims, as well as codes to do so:

    1. CDS mechanism consulted: proposed to develop new G-codes that map to each qualified CDSM
    2. Whether the order adheres to AUC, does not adhere to AUC, or no criterion are applicable: proposed to develop a new series of HCPCS modifiers that provide information about the appropriateness of the order
    3. National provider identification number of the ordering professional

    Guidance for providers: Begin conversations with referring providers and billing staff about the new CDS reporting requirements. Put internal processes in place to ensure that referring providers, particularly those ordering outside of the system EHR, include all necessary information on their claims to safeguard imaging's reimbursement.

    4. CMS proposed adding CDS as a bonus for the Advancing Care Information (ACI) category

    In the MACRA proposed rule, CMS proposed 11 new improvement activities that would be eligible for a 10% bonus in the ACI category beginning in 2018. Arguably, the most notable metric for imaging leaders revolves around CDS; namely, CMS proposes to offer an ACI bonus—otherwise known as a high-weight improvement activity—to ordering providers who attest to using AUC through a qualified CDSM for all advanced diagnostic imaging services.

    Guidance for providers: Organizations that have been working to meet the previously set deadline of Jan. 1, 2018, should highlight this bonus as an incentive for referring providers to continue moving forward with previously established timelines.

    What's next?

    Medicare is accepting comments on their proposals through Sept. 11. We encourage you to submit your thoughts and concerns to CMS. The agency will release the final rule by Nov. 1, 2017.

    In addition to the CDS program, CMS proposed many other changes in the proposed rule, including updates on reimbursement and site-neutral payments. Our team will be posted a larger analysis of the impact on imaging in the coming weeks, so if you aren't subscribed to "The Reading Room" blog, sign up now.


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