The question of where critical access hospitals (CAH) fit within the myriad of clinical decision support (CDS) requirements and exceptions is an ever-present one.  This was made apparent through discussions after Part 1 of our CDS Getting You Prepared webinar series on February 20th and it’s a question we’re hearing from clients frequently as well.  So, we thought we’d take the opportunity to provide further detail into the matter of CAH’s and CDS.

What do we know?

We know that, based on the published CDS-applicable payment systems, CAH’s are exempt from the CDS program.  CAH’s have 2 options for billing; Method I and Method II.

Method I essentially means the hospital and the radiologist bill separately; the CAH files claims to Medicare under their payment system and the radiologist files claims to Part B.

Under Method II, there are two options for billing:

1) The radiologist re-assigns billing rights to CAH, they bill under CDS-exempt payment system and therefore the radiologist is exempt

2) The CAH bills under CDS-exempt payment system AND the radiologist bills Medicare Part B, with no exemption from CDS.

What does this mean to me?

In the case where the radiologist does his/her own billing for Part B services performed in a CAH, the radiologist is required to provide the necessary CDS information on his/her claims for advanced imaging studies performed in the outpatient department or ED.  However, in this scenario the CAH is not required to report anything pertaining to CDS.

What do I do next?

For practices that read at CAH locations, we strongly recommend that a conversation with those locations happens as soon as possible.  In discussions generated from our webinar, CAH’s have little to no knowledge of the CDS program because they are exempt from it.  This poses a potential problem for radiology groups as well as presents the opportunity to provide education.

One suggestion we recommend for radiologists, to ultimately pursue and receive the necessary CDS information from the CAH, is to review your contract or service agreement for language that requires the CAH facility to provide all necessary information for the radiologist to be paid.   We find that most agreements contain this or similar language.

Another option is to utilize a qualified clinical decision support mechanism (CDSM).  All approved vendors are required to provide a free version, which is mostly likely web-based.  In this scenario, a radiology group representative could serve as the trainer for hospital personnel who will be responsible for ordering and consulting CDS as well as maintain communication with the hospital IT department to ensure CDS data elements are flowing appropriately.

As always, ADVOCATE will keep you up to date as industry recommended solutions and further CMS guidance pertaining to CDS become available.


Lauren Sloan, MHA, RD, LD

Director of Regulatory Affairs