2018: More Transitions and Opportunities for Preparation

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In the coming year, let’s get involved and start reporting clinical decision support codes and patient-relationship categories and codes.


In last month’s column, I described 2018 as being a transitional year for the new Medicare Quality Payment Program (QPP). The following two other important CMS initiatives are also transitional in 2018 and should be on our radar: appropriate-use criteria (AUC) for ordering and patient-relationship categories and codes. We can use this transitional year to delay action or to prepare. I suggest that we take advantage of this time to test implementation strategies and to gain experience — without having to worry about potential payment reductions. The ACR Commission on Economics will continue to lead in preparing members for these upcoming mandates, and it will also work with policymakers to ensure a successful implementation.

The Protecting Access to Medicare Act of 2014 requires that CMS “establish a program to promote the use of AUC.” CMS has already approved the provider-led entities (PLE) that may develop AUC and the clinical decision support mechanisms (CDSM) that may deliver it. The ACR was approved for both including the ACR-developed CDSM, ACR Select™. Now that CMS has approved several entities as PLEs and CDSMs, the program implementation is on the horizon. On July 1, 2018, a voluntary reporting period begins for AUC, and a testing period begins Jan. 1, 2019. We have just over a year to gain experience with AUC before payment for imaging services is at risk.

The recent Medicare Physician Fee Schedule Proposed Rule includes language regarding proposed new G-codes, which will be used to document AUC-consultation specifics (see AUC Modifiers sidebar ). The G codes will describe the specific CDSM used, and modifiers will indicate the outcome of the AUC consultation. These G-codes may not be finalized, but some manner of documenting AUC through the claims process will be necessary. Therefore, we will need time to test and gain experience with these new AUC codes.

The transitional period also gives the ACR more time to ensure that the program is implemented properly by CMS to minimize the burden for referring physicians, radiologists, and patients while ensuring proper ordering across a comprehensive range of clinical conditions. You can find dedicated materials on AUC preparation at acr.org/ CDS. Also consider getting started with R-SCAN™ to kick off collaboration between referring physicians and radiologists (learn more at rscan.org).

The Medicare & CHIP Reauthorization Act (MACRA) mandates that CMS develop clinical episode groups to enable cost determination (via resource-use data). While cost is one of the four performance categories under the Merit-Based Incentive Payment System (MIPS), cost will not be scored in 2018. However, it will be worth 30 percent of our final score in 2019. To determine cost, patients within episodes must be attributed to one or more clinicians. For example, a patient admitted with a hip fracture who undergoes hip surgery might trigger an episode group. From there all relevant services provided during that episode must be attributed to a specific clinician. In other words, CMS wants to determine who is responsible for what. To that end, MACRA mandates the creation of patient-relationship categories and codes. The Patient-Relationship Codes sidebar lists the new patient-relationship categories and applicable modifiers. Effective Jan. 1, 2018, one of these modifiers must be appended to every claim. For instance, when a radiologist reads an MR, she must indicate with a modifier her relationship to the patient for whom she provided the interpretation. The same applies to interventional radiology and radiation oncology services. The 2018 transitional period allows us not only to gain experience with the codes but, more important, to decide who we are under the patient-relationship category paradigm. Are we category X5 (“only as ordered”) or are we more consultative, such as category X4 (“episodic/focused”)?

The year 2018 is an important one for radiology. The QPP, AUC, and patient-relationship codes are all being transitioned from statutory mandates to active policy. The go-live date for each is not far away, which gives practices the opportunity to test implementation strategies without fear of payment penalties. Together, the ACR Commission on Economics and CMS will work to ensure appropriate implementation, striving for successful outcomes for radiology patient care. 


dr silva By Ezequiel Silva III, MD, FACR, Chair

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