7 things you need to know now about appropriate use and clinical decision support

For physicians who treat Medicare patients, everything changes next New Year’s Day.

That’s when real consequences begin to befall those who order advanced imaging—CT, MRI or PET scans—without first consulting appropriate use criteria (AUC). They’ll need to show they did so by using a CMS-qualified clinical decision support mechanism (qCDSM).

The ordering physician is not required to go along with the CDSM’s recommendations. He or she just needs to show that a mechanism was consulted. Still, the development represents a big and binding step in the evolution of medical reimbursement in the U.S.

This didn’t come from out of the blue. Medicare’s AUC program is a linchpin in the Protecting Access to Medicare Act (PAMA) of 2014. A voluntary reporting period during which early adopters can make a habit of using their qCDSM has been underway since July 2018 and will run through this year.

However, close CMS watchers as well as attentive healthcare providers can see the writing on the proverbial wall: The future arrives gradually, then suddenly.

One of the close CMS watchers saying as much is Serena Sardo, a radiology coding compliance supervisor with 50-state, 500-radiologist vRad. In a recent conversation with Medical Imaging Review, Sardo outlined seven important yet easily overlooked points about AUC.

1. If you receive payments through CMS’s Hospital Outpatient Prospective Payment System (HOPPS), you will be impacted by the agency’s AUC program.

This goes for hospital outpatient service lines, emergency departments, ambulatory surgical centers, physician offices, provider-led outpatient centers and certain critical-access hospitals.

Which is to say the program has an eye on pretty much every clinician who orders advanced imaging in every setting other than inpatient, Sardo suggests.

“If you’re looking for exemptions and hardships, they’ll apply only under certain strict circumstances—if the patient is critical and is being seen in the ER, for example,” Sardo says. “In those cases the imaging exam would be exempted from having to report a consultation with a qCDSM. And even there, the ordering physician needs to show a true emergency with life-threatening conditions.”

2. CMS’s official AUC timeline is helpful, but it also may be misleading.

The agency has it that 2020 is to be a year of “educational and operations” testing, meaning there’ll be no immediate penalty for lack of compliance. But it’s likely CMS won’t wait to begin compiling data on those who seem to be dragging their feet on AUC acceptance as verified by qCDSM utilization.

Then, in future years—certainly by 2024 but possibly as soon as 2021—many of these slow adopters could be forced to obtain preauthorization for every advanced imaging exam they wish to order.

“You want to catch any issues during the testing period,” Sardo says. “You want to start pinpointing your referrers who are not engaged with this and start working with them before the denials start coming.”

3. Unlike CMS incentive programs, AUC doesn’t offer nice bonuses or threaten percentage penalties. Instead, it’s a straight thumbs-up or -down.

Fail to order with a qCDSM, and you may not bill for the exam at all. Do so repeatedly, and you find yourself on the ‘Preauthorization Required’ list.

“Usually we haven’t seen such a drastic hard line on CMS reimbursement,” Sardo observes. “I think CMS has been taking this very seriously. They really want to reduce costs, and this is one way they’re going to do it. The denial process and the loss of revenue it brings are extremely concerning for everyone in radiology right now.”

On the bright side, many providers have been using a CDSM to report improvement activity, and thus boost their quality scores, through CMS’s Merit-based Incentive Payment System. MIPS began heavily weighting such activities in January 2018, so these providers are well familiar with the CDSM process.

Those who haven’t gotten their bearings on AUC via MIPS are courting trouble if they wait till 2020’s “educational and operations” period to start, Sardo says.

4. Just because a given case seems like a true emergency doesn’t mean it is one (in CMS’s eyes, that is).

In its final rule on AUC, CMS states that neither the rendering physician nor the reading radiologist can make the call on what constitutes a true emergency. “The only person who can attest to it is the ordering physician,” Sardo says. “The orderer does this on the order form, and there is no other way to attest to that exemption.”

Sardo adds that vRad knows this narrow path of exemptions for emergent imaging will vex many ordering providers early on. “We’re trying to do a lot of smart integrations with our order-management system to make this as easy as possible for ER doctors,” she says. “We want to offer as much education as possible on what will be considered an exempt case.”