The right exam for the right reason

Clinical Decision Support

Appropriate Use Criteria / Clinical Decision Support

The Hill Medical Corporation is here to assist in the implementation of CDS. In order to have minimal disruptions to work-flow and caregiver productivity, we have prepared various resources and information to guide clinicians during CDS implementation.

The CMS program was established to increase the appropriateness of the advanced diagnostic imaging services provided to Medicare beneficiaries by subjecting advanced imaging orders to Appropriate Use Criteria (AUC) tools.  The Protecting Access to Medicare Act (PAMA) will require ordering/referring providers to consult Appropriate Use Criteria via a qualified Clinical Decision Support (CDS) mechanism prior to ordering advanced diagnostic imaging services for Medicare patients starting Jan. 1, 2020. The Hill Medical Corporation will be providing referring clinicians with a CDS tool and resources to assist with this new ordering process.

CDS will be required for most:

  • computed tomography (CT)
  • positron emission tomography (PET)
  • nuclear medicine, and
  • magnetic resonance imaging (MRI)

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.

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 alerted 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.
  • While 2020 is an education year, CMS expects consult information to be reported. The agency intends to deny payment for studies for which AUC has not been consulted in 2021 and will penalize outlier physicians with high levels of inappropriate orders in future years.

Major exceptions to the requirements are studies performed on inpatients and emergency medical conditions requiring immediate medical attention. Medicare Advantage plans also are excluded from the requirement. We recommend that you frequently check the CMS website for updates.

CDS Implementation Helpline

Please email or leave us a voice message with the following information, and a representative will contact you within 48 hours.

1. EMR Vendor

2. Physician or Medical Group name

3. Your name and phone number

(626) 701-5826

Thank you for your support as we all move towards value based healthcare.

Beginning January 1, 2023 CDS outliers will be identified, potentially affecting physician reimbursement and requiring pre-authorization for Medicare patients.

Clinical Decision Support Implementation Timeline:

Clinical Decision Support Implementation Timeline
Source: CY 2019 Medicare Physician Fee Schedule

Using a clinical decision support (CDS) mechanism has the potential to reduce waste significantly, as in fewer delays in care and enhanced communication among physicians. CDS can significantly impact improvements in quality, safety, efficiency, and effectiveness of health care.

Seeing the value in CDS:

  • Increased quality of care coordination and enhanced health outcomes
  • Prevention of some errors and adverse events
  • Improved efficiency, cost-benefit, and provider and patient satisfaction
  • Significantly improves the quality of medical imaging care
  • Ordering the right exam at the right time improves the value of care

Other benefits:

  • Use of CDS is high-weight improvement activity under MIPS—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.
  • Aligns with health system care variation reduction goals
  • Opportunity to improve efficiency of care decision making
  • Opportunity to reduce costs

By employing these guidelines, providers enhance quality of care and contribute to the most efficacious use of radiology.

  • Many CDS applications operate as components of comprehensive EHR systems. Verify that your EMR vendor will add a CDS feature.
  • Plan ahead – educate staff and plan out how CDS will impact your workflow.

Hill Medical’s Radiologists and Technologists are available to help in the process. When you need direct answers to clinical questions about appropriate imaging use, we can help. 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

If your EMR will not supply a CDS component, The Hill Medical Corporation will provide a free CDS portal for referring physicians. The portal will be made available later this year (2019).

American College of Radiology

R-SCAN Web Site Introduction. A project -focused approach to collaboration between clinicians and radiologists to improve imaging appropriateness.

ACR Clinical Decision Support Resources

ACR Appropriateness Criteria

ACR Patient Information Resource

Ten Exams Physicians and Patients Should Question

Appropriateness Criteria Topics and Rating Tables

How PAMA Affects Orders for Imaging

ACR Patient-Friendly Appropriateness Criteria Summary Resource


CY 2016 Physician Fee Schedule (PFS) Final Rule with Comment Period CDS program
(pages 71102-71116 and pages 71380-71382)

CY 2017 PFS Final Rule Additional policies related to CDS program (pages 80403-80428 and 80554-80555)

CY 2018 PFS Final Rule Requirements for consulting and reporting under the Medicare AUC program
(pages 53187-53201 and page 53363)

42 Code of Federal Regulations (CFR) 414.94 

CMS Qualified Clinical Decision Support Mechanisms

Appropriate Use Criteria Program

Appropriate Use Criteria for Advanced Diagnostic Imaging – Voluntary Participation and Reporting Period – Claims Processing Requirements

Health IT.Gov: Clinical Decision Support Resources

Medicare Learning Network Appropriate Use Criteria for Advanced Diagnostic Imaging Fact Sheet

Other Sources

The Integrating the Healthcare Enterprise CDS Order Appropriateness Tracking Technical Framework Supplement

American Board of Internal Medicine Choosing Wisely

National Decision Support Company Web Site

AMA Clinical Decisions Support Resource

MedCurrent Web Site

Medicalis Web Site

Strategic Radiology

Strategic Radiology has developed tools and resources to assist affiliated hospitals and members, like The Hill Medical Corporation to prepare for Clinical Decision Support (CDS) implementation. Strategic Radiology LLC (SR) is a nationwide membership organization of quality-focused, private radiology practices dedicated to performance improvement through data aggregation and sharing best practices. The organization represents 26 geographically dispersed, independent radiology practices that provide medical imaging services to more than 250 hospitals and 625 outpatient sites in about 40 states. The organization is wholly owned by its membership and governed by physician officers and physician Executive Committee members.

Strategic Radiology operates the only radiology-specific Patient Safety Organization listed by the Agency for Healthcare Research and Quality. Officially listed in 2013 by the AHRQ, the SR-PSO was recently re-listed.

Information presented was assembled in April 2019 based on current information from CMS, which is subject to change after publication. Clinicians should check the CMS website regularly for updates.