For imaging leaders and radiologists, some of the biggest news coming out of the Medicare Physician Fee Schedule final rule for calendar year 2017 concerns new details about the imaging clinical decision support (CDS) mandate, or the Medicare Appropriate Use Criteria Program.
The rule released earlier this month by Centers for Medicare and Medicaid Services (CMS) most notably set January 1, 2018 as the deadline for referring providers to begin consulting CDS when placing advanced outpatient imaging orders, and for furnishing providers to submit documentation of CDS use on Medicare claims for reimbursement.
While we still do not have all of the details, the rule provided significant clarity on the program, and allows us to offer strategic guidance to ensure that imaging programs comply with mandate.
CDS: A brief refresher
In the Protecting Access to Medicare Act (PAMA) of 2014, Congress included a mandate that ordering providers consult appropriate use criteria (AUC) via electronic CDS when ordering outpatient advanced imaging exams for Medicare patients.
The legislation required CMS to provide implementation details around four key components of the program:
- Approval process for AUC: The clinical guidelines that providers consult to comply with the mandate
- Approval process for CDS mechanisms: The electronic tools that allow providers to consult AUC during ordering
- Provider requirements: How ordering providers will demonstrate that they consulted AUC through an approved mechanism, how furnishing providers will submit that information to CMS, and how CMS will penalize those providers who do not comply
- Identification of outlier providers: How CMS will identify up to 5% of ordering providers as outliers and require them to obtain preauthorization when ordering imaging for Medicare patients
Last year’s rule focused on the appropriate use criteria component, outlining who can create and modify clinical guidelines. Over the summer, the agency released a list of eleven organizations that are approved to create and modify clinical guidelines—meaning that organizations can use AUC created by these organizations to comply with the mandate.
|Qualified provider-led entities as of July 2016
|American College of Radiology
|Brigham and Women's Physician Organization
|CDI Quality Institute
|Massachusetts General Hospital, Radiology
|National Comprehensive Care Network
|Society for Nuclear Medicine and Molecular Imaging
| University of California Medical Campuses
|University of Washington Physicians
|Weill Cornell Medical Physicians Organization
This list will grow with time, as CMS will accept new applications for provider-led entities on January 1 of each year.
The new final rule contains the following takeaways for providers regarding the other components and the program as a whole.
1. Deadline finalized: January 1, 2018
The agency finalized the 2018 deadline, proving clarity around when ordering providers must consult CDS and furnishing providers—most commonly radiologists—must submit claims documenting that consultation.
CDS regulatory timeline
Strategic guidance for imaging leaders and radiologists: The first step to effective CDS implementation is engaging stakeholders. CDS is a multidisciplinary tool, and therefore success relies on multidisciplinary engagement across the system. Use our tools and resources to prime ordering providers, assemble a CDS team, and educate all stakeholders.
2. Ordering providers must consult CDS for all outpatient advanced imaging exams—and radiologists’ reimbursement depends on documenting ordering providers’ use
CMS addressed the scope of the mandate in its recent rule. The law requires CDS use for every outpatient advanced imaging exam ordered for Medicare fee-for-service patients.
While the ordering provider must consult CDS during ordering, the furnishing provider is responsible for reporting that this consultation took place. CMS plans to use claims-based reporting requirements to track compliance. The specific requirements will be elaborated on in next year’s rule, but CMS did suggest that furnishing providers must report three items on claims for full reimbursement:
1. CDS mechanism consulted
2. Whether the order adherence to AUC, does not adhere to AUC, or no criterion are applicable
3. National provider identification number of the ordering professional
Strategic guidance for imaging leaders and radiologists: This is a reminder that although the mandate focuses on ordering provider use, radiologists’ reimbursement is a stake for noncompliance. Imaging leaders and radiologists should play a key role in implementing CDS, educating ordering providers, and ensuring the program is successful.
3. Outlier status for ordering providers will be determined by adherence to eight priority clinical areas
But while CDS use will be required for all outpatient exams, the agency will determine referrer outliers by adherence to priority clinical areas. These areas are diagnostic groups with the highest associated advanced imaging volumes. The agency finalized eight areas, which cover about 40% of all Medicare imaging volumes.
Adherence to CDS in these areas will be used to identify outliers beginning in 2020. Those outliers, up to 5% of order providers, will be required to obtain preauthorization for Medicare patients.
So the priority clinical areas do provide a floor of sorts for the mandate, as AUC across these eight areas are the minimum required for CDS mechanisms to include. However, regardless of the scope of AUC in your CDSM, radiology reimbursement will be at stake for all outpatient advanced imaging, not just those within these eight areas.
Put another way, ordering providers must consult CDS for all outpatient imaging; and without proper claims-based documentation, radiologists’ will not receive Medicare reimbursement.
Strategic guidance for imaging leaders and radiologists: Ensure that the AUC your organization chooses to implement through a CDS mechanism encompasses all eight of these areas. And ensure that the CDS mechanism you choose can provide the analytics you will need to calculate outliers yourself.
Use our tools and resources to identify and educate ordering providers that are not adhering to guidelines in order to improve performance before CMS targets these providers as outliers.
4. Requirements finalized for CDS vendors, with approved list to be released in June 2017
As expected, much of the 2017 rule focused on the CDS mechanism (CDSM), which is the tool that allows providers to consult AUC electronically when ordering imaging exams. Similar to the AUC approval process, CMS has laid out a set of requirements that CDSMs must meet in order to qualify, and invited vendors to apply each year (starting in 2017), with the list of approved CDSMs published by June 30.
CDSM requirements with greatest significance for providers
||What requirement means for providers
|CDSM can incorporate AUC from more than one approved source
||Rather than relying on a single source for AUC content, providers may select AUC from multiple approved PLEs
|CDSM documents ordering provider consultation with a unique identifier, e.g. number or code
||Furnishing providers will submit this identifier, which proves that the ordering provider consulted CDS, on claims for reimbursement
|CDSM delivers aggregate feedback annually to provider
||Ordering providers and organizations will have access to aggregate data to identify trends in utilization and appropriateness
CMS will grant two different types of qualification statuses for CDSMs in this first year:
1. Full qualification: CDSM meets all requirements by the March 1, 2017 application deadline of March 1
2. Preliminary qualification: CMS meets most, but not all, requirements by 2017 application deadline; CDSM demonstrates a clear timeline for when and how it will meet all requirements by January 1, 2018 for the provider deadline.
CDSMs granted preliminary qualification status must meet all requirements by January 1, 2018 or the CDSM will be de-qualified and must notify all providers of this de-qualification status.
CDSMs will be finalized for five years. CMS will release the first list of qualified CDSM no later than June 30, 2017.
Strategic guidance for imaging leaders and radiologists: Use our tools and resources to select a CDS vendor that meets all requirements of the mandate. Ensure the vendor can help advance your imaging program and organization toward larger institutional goals.
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