The right exam for the right reason

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.