CDS Deadline Moves Forward Under CMS
The PAMA requirement has been reconfirmed for referring providers to consult AUC for advanced diagnostic imaging services starting Jan. 1, 2020.
Following the implementation dates and guidelines for Appropriate Use Criteria (AUC) is both important and confusing. Here are the most current mandates to maintain your reimbursement status.
WHEN WILL PROVIDERS BE REQUIRED TO USE AUC WHEN ORDERING IMAGING?
Section 218(b) of PAMA directed CMS to establish a program mandating ordering physicians to consult AUC prior to referring Medicare beneficiaries for advanced diagnostic imaging services. The program was originally slated to begin Jan. 1, 2017. However, due to concerns about physician readiness and the timing of the Medicare Physician Fee Schedule (MPFS) rulemaking cycles, enforcement has been delayed. Implementation of the mandatory AUC consultation mandate is now scheduled for Jan. 1, 2020.
TO WHOM DOES PAMA APPLY?
PAMA mandates that AUC be consulted for all advanced diagnostic imaging services performed for Medicare patients in the physician’s office, independent diagnostic testing facility, and hospital outpatient setting. CMS stated in the 2017 MPFS final rule that it does not have statutory authority to limit the consultation requirement to certain clinical areas.
The first qualified CDS mechanisms to support the rule were announced on June 30, 2017. In the 2019 MPFS final rule, CMS indicated that furnishing professionals (those performing the imaging) would be required to begin reporting AUC consultation on Jan. 1, 2020. The first year of the program will be an “operations and testing period” during which the AUC consultation will be required, but CMS will not impose penalties if the consultation information is incorrectly reported on the claim. The agency noted that this educational period would allow professionals to actively participate in the program while avoiding
claims denials during the learning curve. It should also give CMS an opportunity to make any needed claims-processing adjustments before payments are impacted.
IS REPORTING IN 2018 AND 2019 VOLUNTARY?
CMS began a voluntary reporting period to begin in July 2018, using a new Healthcare Common Procedure Coding (HCPC) System modifier, “QQ.” This is consistent with the Quality Payment Program provision to give Merit-Based Incentive Payment System credit to ordering professionals for consulting AUC using qualified CDS as a highweight improvement activity for the performance period beginning Jan. 1, 2018.
HOW DO THE ACR APPROPRIATENESS CRITERIA FACTOR IN?
In conjunction with the release of the 2018 MPFS proposed rule, CMS announced the list of qualified CDS mechanisms and new qualified provider-led entities on its website. The ACR is one of the qualified provider-led entities, meaning that ACR’s Appropriateness Criteria® (AC) are considered by CMS to be “applicable AUC.” The National Decision Support Company’s CareSelect® Imaging, which incorporates the AC, is on the list of qualified CDS mechanisms and is one of three qualified mechanisms that currently include a free online portal option for providers.
HOW WILL THE AUC CONSULTATION BE REPORTED ON CLAIMS?
The agency proposed specific claims-processing instructions for the AUC program, namely establishing a series of HCPC System Level III codes in the 2018 MPFS proposed rule. These G-codes (reporting codes developed by CMS) would describe the specific CDS mechanisms that were used by the ordering professional. CMS also proposed the use ofseveral modifiers to indicate whether the ordered test was adherent with the AUC requirement.
ACR had some concerns with the proposed claims processing instructions and submitted recommendations to CMS suggesting the use of a unique consultation identifier (UCI) produced by the qualified CDS mechanisms. In the 2018 MPFS final rule, the agency indicated that it would move forward with exploring the UCI concept in the 2019 rulemaking process. Due to complications with Medicare claims forms, CMS was unable to come up with a proposal for the use of a UCI for the 2019 MPFS proposed rule. To move forward with the program implementation date of Jan. 1, 2020, CMS again proposed the use of G-codes and modifiers as a temporary solution while continuing to explore the UCI concept.
WHAT ARE THE CONSEQUENCES FOR PROVIDERS WHO DO NOT FOLLOW AUC GUIDELINES?
The PAMA statute requires the identification of outlier ordering professionals who will be subject to a prior authorization requirement beginning Jan. 1, 2020. With the delayed implementation, CMS will also delay the identification of outlier ordering professionals. This will be discussed in future rulemaking.
The list of priority clinical areas will serve as the basis for identifying outlier ordering professionals and includes the following clinical conditions: coronary artery disease (suspected or diagnosed), suspected pulmonary embolism, headache (traumatic and nontraumatic), hip pain, low back pain, shoulder pain (to include suspected rotator cuff injury), cancer of the lung (primary or metastatic, suspected or diagnosed), and cervical or neck pain. Future MPFS rules will provide further clarity on the concept of prior authorization.
ARE THERE ANY EXCEPTIONS?
PAMA allows for some exceptions to the AUC consultation mandate. Consulting and reporting are not required for orders for applicable imaging services made by ordering professionals under the following circumstances: 1) when emergency services are provided to individuals with emergency medical conditions, 2) for inpatients for whom payment is made under Medicare Part A, and 3) when ordering professionals are granted a significant hardship exception to the Medicare EHR Incentive Program payment adjustment for that year.
CMS acknowledged that most of the exempt emergent situations will occur primarily in the ED, but these situations may arise in other settings. Further, the agency recognizes that most encounters in the ED are not for an emergency medical condition. The rule states, “To meet the exception for an emergency medical condition, the clinician only needs to determine that the medical condition manifests itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in: placing the health of the individual (or a woman’s unborn
child) in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part.” In the 2018 rulemaking cycle, CMS proposed to create a G-code to indicate that an ordering professional is exempt from the requirement.
The 2019 MPFS proposed rule included the following situations that would qualify for significant hardship exceptions: 1) insufficient Internet access; 2) EHR or CDS vendor issues (including temporary
technical problems, installation or upgrades that impede access, or CMS de-qualification of a CDS vendor); or 3) extreme and uncontrollable circumstances (including natural or man-made disasters).
WHEN WILL WE RECEIVE MORE INFORMATION?
The ACR submitted detailed comments on the proposed rule to CMS in September, and we expect to have received further information when the final rule is published in late October/early November (not available at the time of this issue’s printing).
WHAT SHOULD I DO NOW?
The ACR recommends that radiologists communicate with their referring physicians to ensure that they are aware of the forthcoming mandate. ACR also encourages providers to participate in R-SCAN®, a collaborative action plan that brings radiologists and referring clinicians together to improve imaging appropriateness through the use of CDS.
In addition, as we get clarity around the claims-formatting requirements, radiology practices should begin the dialogue with their practice management vendor or billing company. Systems must be ready to accept the AUC data generated by the qualified CDS mechanism, because, as of January 2021, all claims will need to be properly formatted to be payable.
By Kathryn J. Keysor, senior director, ACR Economics and Health Policy