The Reading Room

What Medicare's 2018 rules mean for imaging CDS

by Lea Halim and Ty Aderhold

CMS's recently released Medicare Physician Fee Schedule and Quality Payment Program (QPP) final rules for calendar year 2018 include new details about the imaging clinical decision support (CDS) mandate, also known as the Medicare Appropriate Use Criteria Program. Most significantly, Medicare delayed the CDS provider deadline to Jan. 1, 2020. For more details on this delay and other CDS updates, read on to get our four major takeaways from this year's rulemaking.  

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.

1. CDS implementation deadline delayed until Jan. 1, 2020

After proposing to postpone the provider deadline to 2019, CMS finalized an additional delay, officially moving the deadline from Jan. 1, 2018 to Jan. 1, 2020. This means that ordering providers will be expected to consult AUC and furnishing providers are expected to confirm this consultation on claims submitted to Medicare starting on Jan. 1, 2020. The first year of this program, from Jan. 1, 2020 to Dec. 31, 2020, will be an "educational and operations testing period," CMS said, with Medicare paying all claims regardless of whether they properly include AUC consultation information. Claims denials and reimbursement penalties are expected to begin on Jan. 1, 2021.

While CMS delayed the mandatory deadline, the agency maintained a July 2018 start date for voluntary reporting. During this period, furnishing providers may use a single HCPCS modifier on claims to indicate that the ordering professional provided information on AUC consultation.

Timeline for Clinical Decision Support

Guidance for providers: While the two-year delay in the CDS deadline may lead some programs to pause implementation, we believe that organizations should continue to move forward with CDS and use the additional time to ensure a successful deployment. Organizations now have the opportunity to conduct comprehensive product testing, educate and train ordering providers on the importance of CDS adherence, and systematically roll out CDS across their system. Check out our tools and resources designed to help imaging leaders throughout the CDS implementation process.

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2. CDS now formally aligned with MACRA

In the CY 2018 final rule implementing MACRA's Quality Payment Program (QPP), CMS finalized the proposal to include AUC consultation using CDS as a high-weight improvement activity. Ordering providers can earn 20 points out of the 40 needed for full credit in the Improvement Activities category by demonstrating the use of CDS.

Providers who have satisfied a minimum score in the Advancing Care Information category have the opportunity to receive an additional 10-point bonus in that category for reporting CDS consultation as an improvement activity.

Improving quality and reducing cost, the remaining two MIPS performance categories, directly align with the overall goals for CDS. And CDS implementation can directly impact performance on several quality measures, including:

  • Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients;
  • Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI); and
  • Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients.

For more generalized information on MACRA, read our initial 10 takeaways from the 2018 final rule.

Guidance for providers: The formal alignment of the AUC program with MACRA provides incentive for ordering providers to continue with CDS implementation despite the deadline delay. To encourage ordering providers to move forward, imaging programs can highlight how early adopters of CDS benefit in the 2018 MIPS performance categories. As an added benefit, early implementation allows all stakeholders to work through any challenges well ahead of the Jan. 1, 2020 deadline.

3. Proposals around documentation, hardship exemptions not finalized

No G-Code, HCPCS modifier combination for reporting

While the ordering provider must consult CDS, the furnishing provider is responsible for reporting that this consultation took place. This reporting must include three separate items: the CDSM consulted, the AUC adherence, and the national provider identification number of the ordering professional.

CMS proposed to develop new G-Codes to map to each qualified CDSM and a new series of HCPCS modifiers to provide information on the appropriateness of the order. However, the agency did not finalize this proposal after significant pushback from commenters on the added complexity of this reporting system. Instead, CMS plans to continue to explore "development of unique AUC consultation identifiers" and "mechanisms for CMS and qualified CDSMs to share data." This will likely be a focus of future rulemaking.

No changes to significant hardship exemptions

CMS also chose not to finalize changes to the AUC program's hardship exemptions. After the agency reviewed the comments on the proposal to align the exemptions more closely with ACI, the agency decided to not move forward. Instead, it plans to return to its policies on significant hardship exemptions in rulemaking for CY 2019.

Guidance for providers: With these two changes, CMS has demonstrated a willingness to work with imaging leaders in order to ensure the success of the AUC program. We recommend that providers become involved in the voluntary reporting period in order to identify basic reporting challenges prior to the Jan. 1, 2020 deadline.

Two approval categories for Clinical Decision Support Mechanisms (CDSMs)

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 Jan. 1, 2019. While CMS delayed the CDS deadline until Jan. 1, 2020, the agency made no mention of delaying the 2019 date by which CDSMs granted preliminary qualification status must meet all requirements. As of now, any CDSM with preliminary qualification status that does not meet these requirements by this deadline will be considered not qualified and must notify all providers of this updated status.

*Free tool available.

Guidance for providers: Stay 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.

Other program clarifications of note:

  • CMS has exempted Critical Access Hospitals (CAHs) from the CDS program, meaning that advanced imaging service furnished in CAHs do not require AUC consultation or reporting.
  • The agency did not provide any further information on the exemption for emergency services, which currently applies to emergency services provided to individuals with emergency medical conditions. More details on how these cases will be handled are expected in future rulemaking.
  • CMS also did not provide further information on how furnishing providers should handle updated or modified orders, but the agency acknowledged this issue and stated that it will be addressed in future rulemaking. 

How will the 2018 Medicare final rules affect your imaging strategy?

Join us on December 7 to learn how we saw outpatient imaging care evolve in 2017 and what the 2018 Medicare final rules for hospital and physician reimbursement will mean for your organizations.

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