When do I need to start consulting a clinical decision support mechanism?


Jonathan Rubenstein, MD, and Mark Painter address the coding question: My local hospital tells me that starting Jan. 1, 2020, I have to consult a Clinical Decision Support Mechanism due to the Appropriate Use Criteria program. I thought that didn’t start until 2021. Can you help?

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Jonathan Rubenstein, MD

Mark Painter

My local hospital tells me that starting Jan. 1, 2020, I have to consult a Clinical Decision Support Mechanism due to the Appropriate Use Criteria program. I thought that didn’t start until 2021. Can you help?

We have heard similar comments from various areas around the country. For background purposes, the Appropriate Use Criteria (AUC) program was established by the Protecting Access to Medicare Act of 2014 (PAMA) to increase the rate of appropriate advanced diagnostic imaging services furnished to Medicare beneficiaries. The program requires that ordering providers consult a qualified Clinical Decision Support Mechanism (CDSM) and document the consultation results when ordering advanced imaging services for Medicare beneficiaries performed in hospital outpatient departments (including emergency rooms), independent diagnostic testing facilities, offices, and ambulatory surgical centers.

Forms of advanced imaging included in this regulation are computed tomography, magnetic resonance imaging, nuclear medicine, and positron emission tomography scans. Emergency services and inpatient services are exempt from this regulation, and there are also hardship exemptions available.

A CDSM is an interactive, electronic tool for use by clinicians that communicates AUC information to the ordering provider to assist them in making the most appropriate treatment decision for a patient’s specific clinical condition during the patient’s workup. The CDSM will provide the ordering professional with a determination of whether that order adheres to AUC, does not adhere to AUC, or if there is no AUC applicable (for example, no AUC is available to address the patient’s clinical condition) in the CDSM consulted.

The imaging test will be given a grade on appropriateness, which then gets transmitted to the imaging facility. The imaging facility will then apply AUC-related HCPCS code(s) to the CPT line item. The burden for consulting a CDSM ultimately is placed onto the ordering provider, not the radiology facility.

Since imaging facilities must place AUC-related HCPCS codes on claims, ordering providers who do not consult a CDSM likely will not have their imaging tests performed. The “results” of the consultation also affect the ordering providers, as those whose ordering patterns are considered to be outliers may be subject to prior authorization when ordering advanced imaging services.

You are correct that according to the regulations, reporting will be mandatory for payment to imaging centers starting on Jan. 1, 2021. However, the Centers for Medicare & Medicaid Services was scheduled to begin its “educational and operations testing period” on Jan. 6, 2020 to allow providers and radiology centers to test the system, and the AUC-related HCPCS modifiers will be accepted on claims; claims will not be denied before Jan. 1, 2021 if no HCPCS modifiers are submitted. However, that does not keep hospitals and radiology centers from themselves demanding a CDSM consultation starting now, as they are preparing themselves for the 2021 calendar year. This may be what is going on with your local hospital.

How does this affect an ordering professional in the 2020 calendar year, even if one resides in an area where the local radiology centers do not yet require a CDSM consultation? We are still trying to fully understand the regulations, and we cannot find a definitive answer at this time. PAMA requires that the program results in prior authorization for ordering professionals whose patterns are considered outliers, but before the prior authorization component of this program begins there will be notice and comment rulemaking to develop the outlier methodology.

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Therefore, some interpret this to mean that even in the 2020 calendar year, providers will not yet see the prior authorization restrictions; however, that also does not mean that CMS is not collecting the data. Therefore, we feel it is of the utmost importance to understand the PAMA requirements and to start the process for your practice to comply with these regulations.

In addition, there has been some chatter within the physician community to halt further implementation of the AUC program and instead encourage AUC consultation through the Quality Payment Program and other value-based initiatives. Therefore, just like many other CMS programs, the regulations could change suddenly at any time or the program could even disappear altogether.

We encourage you to work with your local radiology centers to determine their plans regarding compliance with the AUC for 2020 and in the future, and with your EHR vendor to determine if and how they are going to allow you to access a CDSM and which qualified CDSM they have decided to work with for the program. A list of qualified CDSM programs is included on the CMS website (bit.ly/CDSMinfo).

Additional information:

• Medicare Learning Network Fact Sheet: Appropriate Use Criteria for Advanced Diagnostic Imaging: bit.ly/AUCfactsheet

• Medicare Learning Network article “Appropriate Use Criteria for Advanced Diagnostic Imaging – Voluntary Participation and Reporting Period – Claims Processing Requirements – HCPCS Modifier QQ”: bit.ly/AUCarticle

• CMS.gov – Appropriate Use Criteria Program: bit.ly/AUCinfo 

Send coding and reimbursement questions to Jonathan Rubenstein, MD, and Mark Painter c/o Urology Times, at urology_times@mmhgroup.com.

Questions of general interest will be chosen for publication. The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.

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