The Reading Room

What Medicare's 2019 proposed rule means for imaging CDS

by Erin Lane and Catherine Kosse

Editor's note: This story was updated on August 21, 2018.

Earlier this month, CMS released the Medicare Physician Fee Schedule (MPFS) and Quality Payment Program (QPP) proposals for calendar year 2019. For imaging, many of the biggest updates concern the imaging clinical decision support (CDS) mandate, also known as the Medicare Appropriate Use Criteria (AUC) Program.

Notably, the agency upheld the January 1, 2020 start date and provided guidance around provider consultation and documentation. Read on to get our six major takeaways from this year's rulemaking—and our guidance on how to respond.

Click here or scroll to the bottom for a refresher on the CDS mandate

The 6 key takeaways from recent CMS proposals

1. AUC Program on track to begin in 2020

In this year's proposed rule, CMS reinforced the January 1, 2020 program start date finalized last year. This means that in 2020, ordering providers must consult AUC, and furnishing providers (radiologists and imaging managers) must document this consultation on both professional and technical claims submitted to Medicare.

The mandatory first year is deemed an "educational and testing" period, meaning claims will be paid regardless of documentation. Beginning January 1, 2021, Medicare will deny claims that do not include necessary information (more on documentation below).

In the meantime, the voluntary reporting period in which providers can report consultation using modifier, QQ, began in July. Ordering providers can attest to CDS consultation to earn Improvement Activity credit and Promoting Interoperability (formally called Advancing Care Information) bonus points in QPP's Merit Based Incentive Payments System (MIPS). For MIPS credit, providers do not need to report the modifier, but they must maintain documentation of CDS for six years. For more information on the AUC program's alignment with MACRA, review our analysis of the 2018 final rules.

Guidance for providers: Although CDS is not mandated for another year and a half, organizations should develop an implementation strategy now. This approach provides the opportunity to conduct comprehensive product testing, educate and train ordering providers on CDS, and slowly roll out CDS across the health system. Encourage ordering providers to participate in voluntary reporting, and emphasize the potential to earn MIPS credit as a benefit to early adoption. To learn more, check out our tools and resources designed to help imaging leaders throughout the implementation process.

2. CMS outlines documentation, but returns to G-codes and modifiers

Ordering providers consult CDS, but furnishing providers are responsible for reporting that consultation took place. This claims-based reporting must include three separate items:

  • CDSM consulted;
  • AUC adherence (adherent, not adherent, or not applicable); and
  • National provider identification (NPI) number of the ordering professional.

CMS proposes to use G-codes for CDSM consultation and modifiers for AUC adherence. CMS requests feedback from stakeholders, as the agency withdrew a similar proposal from the calendar year 2018 rules citing reporting challenges.

Guidance for providers: Radiologists and imaging programs are financially responsible for documenting CDS consultation. Even though we don't know exactly what that process will look like, imaging leaders should start working with their informatics team to prepare for reporting. For more information on how to ensure CDS adherence, review section three of our toolkit.

3. Clinical staff now able to consult CDS

We now have an answer to perhaps the most asked question: Who can consult CDS?

To ease reporting burdens, CMS proposed allowing clinical staff "working under the direction of the ordering professional" to consult CDS. We interpret this to mean that ordering providers may have their staff (but not radiology staff) consult CDS on their behalf.

Importantly, the ordering professional's NPI will be recorded on the imaging claim, whether they or a clinical staff member consulted CDS. This means the ordering professional is responsible for correct consultation; the NPI will be used to identify outlier ordering providers subject to Medicare prior authorization.

Guidance for providers: Understand your state's scope-of-practice laws to learn the definition for clinical staff. If ordering providers plan to have clinical staff order, expand your education efforts to this cohort. Additionally, our team interprets clinical staff to be employees within the ordering provider's organization. In other words, this proposal would not allow radiologists or imaging staff to consult CDS on behalf of ordering providers.

4. CDS required for imaging provided at independent facilities

CMS proposed to include Independent Diagnostic Testing Facilities (IDTF) as a mandatory setting in the AUC program. CDS consultation will be required when imaging is provided in the following care settings:

  • Physician's office;
  • Hospital outpatient department (including non-emergency conditions in the ED);
  • Ambulatory surgery centers; and
  • IDTFs – proposed.

Guidance for providers: Including IDTFs in the definition of applicable settings equalizes the playing field for imaging providers. Ordering providers must consult CDS for all outpatient facility types. Radiology programs must find ways to streamline CDS to differentiate yourself in the market.

5. Potential expansion of hardship exemptions

The proposed rule introduces three new hardship exemptions and the associated reporting mechanism. Specifically, ordering providers will be exempt from consulting CDS if they experience:

These are in addition to two previously finalized exemptions: orders for emergency medical conditions and inpatient services. At a later date, CMS will provide modifiers for exemptions that should be reported on claims.

Guidance for providers: While the proposals clarified lingering questions about hardship exemptions, a few remain. For example, CMS didn't propose a time limit for an ordering provider claiming these exemptions. Additionally, the agency still has not clarified which ED conditions are considered non-emergent and subject to CDS consultation.   

6. Outlier identification still to-be-determined

CMS plans to identify up to 5% of ordering providers as outliers and require them to obtain preauthorization when ordering imaging for Medicare patients. In 2017, CMS finalized eight priority clinical areas that will be used in this process.

In this year's proposed rule, CMS requested public feedback on creating the methodology for outlier identification, particularly around the required data elements and thresholds. CMS will address this in the 2022 or 2023 rulemaking cycles. For more information on the finalized priority clinical areas, read our analysis of the 2017 final rule.

Guidance for providers: Furnishing providers' reimbursement is at risk if ordering providers don’t consult CDS, but the outlier classification is one mechanism to hold ordering providers accountable. Stress the potential for Medicare prior authorization when providing CDS education to these professionals. For more information on talking points, refer to section one of our toolkit.

What's next?

Medicare will accept comments on their proposals until September 10 and release the final rule in early November 2018. We encourage you to submit your thoughts and concerns to CMS.

In addition to the CDS program, CMS proposed many other changes in the rules, including updates on reimbursement. Our team will post a larger analysis of the impact on imaging in the coming weeks on "The Reading Room" blog, but in the meantime review our initial analysis of MPFS and QPP.

A brief refresher on CDS

In the Protecting Access to Medicare Act (PAMA) of 2014, Congress included a mandate for ordering providers to consult AUC 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:

To access the full list of qPLEs, click here.

To access the full list of approved CDSMs, click here.

To access the full list of priority clinical areas, click here.

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