2020 Medicare Mandate/Clinical Decision Support

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Beginning in 2020, CMS will require consultation of Appropriate Use Criteria (AUC) by ordering physicians prior to referring Medicare patients for certain advanced diagnostic imaging services. As a member of Strategic Radiology, a coalition of independent radiology practices, has developed this resource to assist ordering clinicians with information to prepare for implementation. All information is based on current communiques from CMS. We recommend that you frequently check the CMS website for updates.

  1. AUC is a CMS Mandate.
    Ordering physicians must consult appropriate use criteria (AUC) for advanced imaging in designated settings beginning January 1, 2020. Protecting Access to Medicare Act (PAMA) requires ordering clinicians to consult AUC using an approved Clinical Decisions Support Mechanism (CDSM) prior to ordering CT, MRI, Nuclear Medicine and PET studies for Medicare patients. Major exceptions to the requirements are studies performed on inpatients and emergency medical conditions requiring immediate medical attention. Medicare Advantage plans are also excluded from the requirement.
  2. Begin Planning Now.
    You must either install and integrate a CDSM module with your EMR or use a free, open-access CDSM via a web portal, and begin using on January 1, 2020. Your choice will likely depend on the frequency of imaging orders in your practice and the cost of purchasing and installing a CDSM module versus manually consulting a web portal. If you order a significant volume of advanced imaging studies, consult with your EMR vendor to learn which CDSMs have been integrated with your software. Cost and integration functionality vary widely, so carefully review the available options. A list of approved CDSM vendors, and those offering free CDSM’s via a web portal, is available on the CMS website referenced above or available here.
  3. Know the Mechanics of Advanced Imaging Order Requirements.
    This program is a CMS work-in-progress, so more will be revealed over time. This is what we know now:

    • Before the end of 2019, CMS will issue HCPCS G-codes that correspond to each approved CDSM, along with a set of modifiers to indicate whether or not an order conformed to AUC or an exception applied.
    • For each order, imaging providers will need to receive the applicable G-code for the CDSM used by the ordering clinician, and the appropriate modifier for the AUC consultation, along with the NPI of the ordering clinician.
    • If you send imaging orders electronically via HL7, those interfaces will need to be updated to include this information
  4. CMS Expectations and Incentives.
    • CDSMs will give ordering clinicians information about the most appropriate study for given clinical indications, and trade-offs between options.
    • Ordering Clinicians may delegate AUC consultation to trained clinical staff working under their supervision, however CMS expects that ordering clinicians will be alerts in cases where a more appropriate study is suggested. The AUC process may not be delegated to furnishing providers such as outside imaging centers or radiologists.
    • If you begin AUC consultation before October 1, 2019, you can earn credit for a 2019 Improvement Activity under the MIPS program, earning 20 points out of the 40 needed for full credit.
    • Early adopters also have demonstrated that there may be an opportunity to use AUC consultation via a CDSM to negotiate a reduced pre-authorization burden with commercial payors.
    • White 2020 is a test year during which CMS will collect data, the agency intends to deny payment for studies for which AUC has not been consulted in 2021 and penalize outlier physicians with high levels of inappropriate orders in future years.
  5. We Can Help.
    When you need a straightforward answer to clinical questions about appropriate imaging use, please reach out to our radiologists. The following situations may require further consultation:

    • Unusual problems that involve difficult tradeoffs
    • Combinations of problems that make traditional strategies of care problematic
    • The interpretation of conflicting information
    • Decisions that need to reflect individual patient preferences

Direct AUC Questions to: Kacie Kurdy
Telephone: 203-267-3340 x 1143
Email: kkurdy@nvranet.com