PAMA Pushes AUC Forward
Following the implementation dates and guidelines for Appropriate Use Criteria is both important and confusing. Read the most current mandates to maintain your reimbursement status.
When will providers be required to use Appropriate Use Criteria when ordering imaging?
Section 218(b) of the Protecting Access to Medicare Act of 2014 (PAMA) directed CMS to establish a program beginning on Jan. 1, 2017, mandating ordering physicians to consult Appropriate Use Criteria (AUC) prior to referring Medicare beneficiaries for advanced diagnostic imaging services. However, due to implementation problems, enforcement has been delayed. The AUC are defined as criteria that are evidence-based (to the extent feasible) and assist professionals who order and furnish applicable imaging services to make the most appropriate treatment decisions for a specific clinical condition. The ACR has created and updated such criteria for decades, and these resources will be applicable under the AUC mandate.
To whom does PAMA apply?
The PAMA legislation mandates that AUC be consulted for all advanced diagnostic imaging services. CMS stated in the 2017 Medicare Physician Fee Schedule (MPFS) final rule that it does not have statutory authority to limit the consultation requirement to certain clinical areas. While the statutory language mandated an effective date of Jan. 1, 2017, the timing of the rulemaking process used by CMS made it extremely difficult to achieve this implementation date. In the MPFS final rule, CMS indicated that it will continue to aggressively implement this AUC program, and the first qualified clinical decision support mechanisms (CDSMs) to support the rule were announced on June 30, 2017. The agency expected that furnishing professionals (those performing the imaging) would be required to begin reporting AUC consultation on Jan. 1, 2018. CMS also indicated in the final rule that there was to be further rulemaking issued and completed in 2017 for calendar year 2018, which, indeed, has come to pass.
Is that enough time?
In the 2018 MPFS proposed rule, CMS acknowledged concerns raised by many medical specialty societies about their readiness for a Jan. 1, 2018, start date and their requests that the agency delay until after implementation of the Quality Payment Program (QPP). As a result, CMS proposed moving the date to Jan. 1, 2019. Due to the complex nature of the AUC program, CMS also proposed an “educational and operations testing period” as part of the implementation lasting one year beginning Jan. 1, 2019. During this period, ordering professionals (referring physicians) would consult AUC and furnishing professionals would report AUC consultation information on the claim, but CMS would continue to pay claims whether or not the correct information was included. 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 would also give CMS an opportunity to make any needed claims-processing adjustments before payments are impacted.
Will reporting be voluntary or required?
CMS expects a voluntary reporting period to begin around July 2018. The timing of this opportunity for voluntary reporting is dependent on the readiness of the Medicare claims system to accept and process claims that include AUC consultation information. This is consistent with the proposal in the recently released QPP proposed rule to give Merit-Based Incentive Payment System (MIPS) credit to ordering professionals for consulting AUC using a qualified CDSM as a high-weight 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 MPFS proposed rule, CMS announced the list of qualified CDSMs and new qualified provider-led entities on its website. The ACR Select® program, which incorporates the ACR Appropriateness Criteria®, is on the list of qualified CDSMs and is the only qualified mechanism that currently includes a free web-based 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 Healthcare Common Procedure Coding System level-3 codes. These G-codes (reporting codes developed by CMS) would describe the specific CDSMs that were used by the ordering professional. CMS also proposed the use of several modifiers to indicate whether the ordered test was adherent with the AUC requirement. The ACR has some concerns with the proposed claims-processing instructions and submitted recommendations to CMS.
What are the consequences for providers who do not follow AUC guidelines when ordering imaging?
The PAMA statute requires the identification of outlier ordering professionals, who will be subject to a prior-authorization requirement beginning on Jan. 1, 2020. With the delay of implementation until Jan. 1, 2019, it is likely that 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), cervical or neck pain. Future MPFS rules are expected to 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 requirements 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 Electronic Health Record Incentive Program payment adjustment for that year.
CMS acknowledged that most of the exempt emergent situations will occur primarily in the emergency department but that these situations may arise in other settings as well. Further, the agency recognizes that most encounters in the emergency department 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.
When will we receive more information?
While the MPFS proposed rule released in July provided some additional details on program implementation, there continue to be some questions and concerns about these proposals. 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 yet available at the time of this 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. Referring physicians should become familiar with the available CDSM options (including ACR Select®) posted on the CMS website (bit.ly/CDSmechanisms). The ACR also encourages providers to participate in the free Radiology Support, Communication, and Alignment Network (R-SCAN®), a collaborative action plan that brings radiologists and referring clinicians together to improve imaging appropriateness through the use of CDS. R-SCAN also has been approved by CMS as an improvement activity under MIPS. Learn more at rscan.org.
By Kathryn J. Keysor, senior director, ACR Economics and Health Policy