The Protecting Access to Medicare Act (PAMA) of 2014 section 218(b) established a new program to increase the rate of appropriate advanced diagnostic imaging services rendered to Medicare beneficiaries. Under this program, before a referring physician orders an advanced imaging service he/she will be required to consult a qualified Clinical Decision Support Mechanism (CDSM). CDSM’s are the electronic portals through which referring physicians access appropriate use criteria (AUC) during the patient workup. The CDSM will provide the ordering physician with a determination of whether that order adheres to AUC, does not adhere to AUC or if there is no AUC applicable. Emergency and inpatient studies are exempt.
Stripped to its basics, CDSM’s are purported to be a set of “clinical guidelines” that will help referring clinicians determine what imaging should be performed based upon the individual patient, scientific evidence, risk/benefit of testing, available healthcare resources, etc. The goal is to improve outcomes and resource utilization. When this program is fully implemented, the legislation essentially mandates that referring physiciansobtain pre-authorization for covered services thru a CDSM prior to referring the patient for imaging for covered services.
Information regarding the ordering physicians CDSM consultation must be appended to the radiologist’s claim. Although it is not settled yet, the reporting mechanism for the voluntary reporting period will be use of Healthcare Common Procedure Coding System (HCPCS) modifier QQ that would be included on claim forms, submitted by the radiologist for the service, to indicate the referring clinician’s use of a CDSM and identifying which CDSM was consulted, there are multiple CDSMs available. There might also be unique identifiers produced by the CDSM’s that could be submitted to indicate CDSM was employed prior to ordering the tests.
Once the legislation is fully implemented, for the radiologist to receive reimbursement from CMS, the radiologists claim must include the modifier QQ. The modifier QQ is reported on the same claim line as the CPT code representing the advanced diagnostic imaging service furnished, and can be reported on both the facility and professional claim. The modifier QQ can only be used when the radiologist has been made aware of the ordering physician’s consultation with a CDSM for that patient.
Voluntary Reporting –
July 2018 Through CY 2019
Effective for claims with dates of service on or after July 1, 2018, CMS contractors will begin accepting the new QQ modifier on the same claim line as the covered CPT codes.
Educational and Operations Testing Period – January 2020 Through December 2020
CMS has established an “educational and operations testing period” during which ordering physicians will be required to consult CDSM and radiologists will report CDSM consultation on claim forms. However, CMS will continue to pay claims during this period even if the information is incorrect.
Go Live – January 1, 2021
Assuming no further delays occur, referring physicians will be required to use CDSM and radiologists will be required to submit modifier QQ beginning January 1, 2021 unless they qualify for a hardship exemption. As it stands now, beginning in January 2021, radiologists who provide the applicable imaging services would have their claims denied by Medicare if no CDSM were used by the ordering physician and submitted by the radiologist.
The impact of this program will be monumental. As written, every physician who orders advanced diagnostic imaging services will be required to utilize a CDSM to obtain approval for the study being ordered, before the study is ordered. Thus, the program would impact every medical specialty that utilizes imaging services. The absurdity of the legislation is it penalizes the radiologist for the referring physician’s behavior or lack of compliance.
There are “hardship exemptions” and emergency and inpatient services are exempted from the program. Also, there is the possibility that ordering physicians who implement CDSM’s might receive credit under the Merit-based Incentive Payment System (MIPs).
As always, ADVOCATE will keep you up to date on this and all issues impacting radiology as they become available.
Lauren Sloan, MHA, RD, LD
Director of Regulatory Affairs