On January 1, 2022, radiology practices and hospitals that perform certain imaging services for Medicare patients will be denied payment for those services unless they submit documentation that the ordering physician has consulted a Clinical Decision Support (CDS) system. This regulation was included a few years ago in Medicare rulemaking, but its effective date has been delayed several times. As of now, there is no reason to believe it will be postponed further, so practices that have not yet taken steps to install and implement a system have a narrow window of opportunity to get ready.
A Review of the Requirements
The regulation requires ordering physicians to consult Appropriate Use Criteria (AUC) using a qualified Clinical Decision Support Mechanism (qCDSM) that is approved by the Centers for Medicare and Medicaid Services (CMS) prior to ordering CT, MR, nuclear medicine and PET exams for outpatients covered by Medicare Part B. It applies to outpatient imaging services performed in the hospital outpatient department, hospital emergency department, radiology office or imaging center, ambulatory surgery center, or in an Independent Diagnostic Testing Facility (IDTF). The site where the imaging is performed, not the ordering site, determines the necessity to use CDS.
There are a few exceptions to the requirement that an AUC consultation take place for the claim to be paid:
- Inpatient services covered under Medicare Part A are not subject to the regulation.
- Services performed at a Critical Access Hospital (CAH) are not subject to the regulation.
- No AUC consultation is required when certain hardship circumstances exist for the ordering professional. These include:
- Insufficient internet access.
- Electronic health records (EHR) or qualified clinical decision support mechanism (qCDSM) vendor issues. For example, issues might include technical problems, installation or upgrades that temporarily impede access to CDSMs, a vendor ceases operation or a CDSM becomes de-qualified.
- Extreme or uncontrollable circumstances (including natural or manmade disasters).
- Services ordered for an individual with an emergency medical condition[1] do not require a consultation, regardless of the location where those services are performed. The ordering physician’s determination of an emergency condition will govern. However, while some are relying heavily on this exception, CMS has indicated that the majority of Emergency Department cases will not be exempt.
In addition to these exceptions, no AUC consultation and reporting will be required by Medicare Advantage plans (Part C) or when Medicare is a secondary payer unless the primary payer has such a requirement. In cases where the radiologist adjusts the exam, such as to add contrast to a non-contrast order, it is not necessary for him or her to consult a CDSM; the original consultation by the ordering physician is sufficient.
While the ordering physician does not have to follow the AUC recommendation of the CDSM, he or she must use the CDSM and provide the imaging facility with the appropriate information to include on their Medicare claim. Our January 2020 article goes into more detail about performing and reporting the AUC consultation.
Practices Should Now Be Testing
Since these regulations have been pending for so long you would suppose that most hospitals and radiology groups are prepared by now, but that unfortunately may not be the case. The Medicare claims system is in place to process the AUC consultation coding on a test basis. Information will be returned to the practice about the adequacy of its submission, but payment will not be denied for missing information. Commercial payers should be contacted about their CDS requirements.
A practice with multiple imaging sites will have to evaluate their readiness at each one. Obviously, preparing at a physician-owned private office or imaging center will be an entirely different process than working with a hospital. Hopefully the hospital realizes that their reimbursement is at risk as much as the radiologist’s is, so the effort to implement CDS should be collaborative. The radiology group might offer to spearhead the project, with compensation from the hospital, if the institution cannot move ahead quickly enough. Quantifying the potential financial impact of payment denials for the affected imaging services might help get things moving if there is resistance.
Regardless of the site of service, the referring physician community has to be educated about the need to consult the CDSM. The consultation must be done by the ordering physician or their staff, not by the imaging facility. The hospital and practice marketing teams should be included early-on to get the word out to the community, including not only those physicians within the same health system, but also those outside physicians who are important referrers to the practice. The education process should include not only the steps required to perform the consultation but also the relevance of the process to improving patient care. If you are not using a CDSM that is part of your own practice’s ordering system, be ready to help the referring office staff to set up their account with one of the free CDSM’s available.
Long-term Implications for Ordering Physicians
CMS will refer to AUC and CDS data to identify the top 5% of providers who most frequently order inappropriate imaging. They will then require prior authorization for any advanced imaging services ordered by those outlier providers. The following priority clinical areas have been identified by CMS:
- Coronary Artery Disease (suspected or diagnosed)
- Suspected pulmonary embolism
- Headache (traumatic and non-traumatic)
- Hip pain
- Low back pain
- Shoulder pain (to include suspected rotator cuff injury)
- Cancer of the lung (primary or metastatic, suspected or diagnosed)
- Cervical or neck pain
Changing Criteria
The American College of Radiology (ACR) periodically updates their Appropriateness Criteria. The most recent revision issued in April 2021 contained 13 new topics and revised 5 others.
Resources
CMS has published several documents that can be useful, and the ACR and MGMA both have good information available:
- MLN Fact Sheet “Appropriate Use Criteria for Advanced Diagnostic Imaging”
- MLN Matters (MM 11268) “Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging – Educational and Operations Testing Period - Claims Processing Requirements”
- For an overview, CMS Appropriate Use Criteria Program
- The American College of Radiology (ACR) Clinical Decision Support Page
- MGMA Toolkit
Conclusion
Time is running out for practices to get ready. Evaluate each site of service to determine which system will be used, and then develop a timetable to thoroughly educate the referring physician community. Working in conjunction with the hospital can be beneficial to get the word out. Be sure to verify that your billing system, whether in-house or outsourced, is ready to capture and transmit the required coding to CMS and test it with a few submissions to be sure everything is ready to go. We will keep you apprised of any changes as the deadline approaches; subscribe to this blog for the latest information.
[1] An “emergency medical condition” is defined under the Emergency Medical Treatment And Labor Act (EMTALA) as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. In addition, with respect to a pregnant woman who is having contractions, an emergency medical condition exists when there is inadequate time to effect a safe transfer to another hospital before delivery, or that transfer may pose a threat to the health or safety of the woman or the unborn child.
Sandy Coffta is the Vice President of Client Services at Healthcare Administrative Partners.
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