Clinical Decision Mandate

With the latest CDS (Clinical Decision Support), also called the Medicare Appropriate Use Criteria (AUC) Program, mandate released for advanced imaging tests, changes could affect more than six million emergency department visits per year. The estimate was published in a Radiology study this January.  This law shall be effective from January 2020.

In 2014, Congress passed the PAMA (Protecting Access to Medicare Act) that put forth rules for CMS to establish AUC Program for all CDS systems implemented in the American health systems serving Medicare beneficiaries. It also maintained that providers not consulting with a compliant CDS system would not get any reimbursement for advanced imaging studies.



Takeaways from the Latest CMS Proposal

 #1: AUC Program Likely to Begin in 2020

In the proposed rule, the start date was finalized. CMS reinforced that January 1, 2020, would be the date. This clearly indicates that from 2020, ordering providers have to consult AUC. In addition, furnishing providers, including imaging managers and radiologists, must document their consultation on both professional as well as technical claims that are submitted to Medicare.

Even though CDS is not mandated for the next one and a half years, organizations should be prepared with a strategy. With this approach, you also have an opportunity to conduct product testing, train providers and educate them on CDS, and encourage them to participate in reporting.

#2: Outlining Documentation and Returning G-codes and Modifiers

While ordering providers have to consult CDS, furnishing providers are mainly responsible for consultation taking place. This is a methodic and claim-based reporting system, which adheres to the following norms:

  • CDSM consultation
  • AUC adherence report
  • National Provider Identification (NPI) number of ordering providers

The responsibility of documenting CDS consultation lies with imaging programs and radiologists. Image leaders should adhere to the guidelines and start preparing reports along with the informatics team.

#3: CDS Consultation for Clinical Staff

Who can consult CDS?

Answering this question, CMS proposed to allow clinical staff working under specific directions of the ordering professionals to consult CDS. This means ordering providers can have their staff, not radiology staff, for CDS consultation on their behalf.

#4: CDS Mandatory for Imaging at Independent Facilities

CMS also proposed to include IDTF (Independent Diagnostic Testing Facilities) in AUC programs. In fact, CDS consultation would be mandatory when imaging is done in the physician’s office, hospital outpatient department (OPD), IDTFs (proposed) and ambulatory surgery centers.

Ordering providers have to consult CDS for all outpatient facilities. Radiology programs should find ways of streamlining CDS and stand out.

#5: Hardship Exemptions

Exempting hardships is also a part of the new mandate. With the latest reporting mechanisms, there are three new exemptions – CDSM or EHR vendor issues, inadequate internet issues, extreme circumstances like area infrastructure, etc.

Vendor issues like technical problems, upgrades or installation issues, and ceased vendor operations are very common.

These exemptions, however, are in addition to the two previously finalized hardship exemptions –emergency medical condition order and inpatient services.

Although this proposal clarified most of the questions about hardships exemptions, some issues remain. For instance, CMS did not propose a specific time limit to order a provider claiming such exemptions.

Final Word

sepStream®  aspires to deliver necessary solutions with respect to the latest CDs mandate. Besides the CDS program, the CMS also proposed several other changes in rules, which includes updates on reimbursement. It would improve care delivery through proper guidelines and evidence-based algorithms.