In the recently released Medicare Physician Fee Schedule Final Rule, CMS provided the final regulations governing the Appropriate Use Criteria (AUC)/Clinical Decision Support (CDS) Program to become effective January 1, 2020. Below are key highlights and pertinent details on the program and the steps we are taking to ensure our clients have the information and tools needed to successfully implement this new program.

The rule requires that AUC be consulted, via a qualified Clinical Decision Support Mechanism (CDSM), by the ordering physician or his/her clinical staff (see definition below), prior to ordering advanced imaging services(CT, MRI, PET, nuclear medicine). AUC specify when it is appropriate to order advanced imaging services. An “appropriate” procedure is one for which the expected health benefits exceed the expected health risks by a wide margin. A qualified CDSM is a CMS-approved electronic tool that the ordering physician or his/her clinical staff must utilize to consult established AUC.

There are free CDSM tools and applications integrated into EHR products, all of which have been approved by CMS and are listed here. If the CDSM is integrated with the EHR it will cause the least workflow disruption but require more resources.

Effective January 1, 2020, the radiologist’s claim to CMS for an advanced imaging service must include the ordering physician’s consultation with the CDSM. Beginning in 2022, the radiologist will not be paid if the ordering physician’s consultation is not documented on their claim to CMS.

Effective at some point in the future, CMS will impose prior authorization requirements on ordering physicians who are identified as non-compliant with the AUC/CDS program; focusing first on the established priority clinical areas.


What should be reported Beginning in 2020?

After the AUC is consulted by the ordering physician or his/her auxiliary personnel via the qualified CDSM, the actual order for the advanced imaging service must include:

  1. Which qualified CDSM was consulted. Each qualified CDSM will be issues a unique G-code by CMS. This unique G-code must be provided by the ordering to the providing physician;
  2. The name and NPI number of the ordering physician; and
  3. A modifier, supplied by the qualified CDSM during the CDSM consultation that will indicate;
    1. whether the service ordered would adhere to the applicable AUC,
    2. whether the service ordered would not adhere to such criteria or,
    3. whether the criteria was not applicable for the services ordered.

To ensure that ADVOCATE systems are fully ready to support AUC/CDS reporting, ADVOCATE is in frequent contact with several CDSM vendors to understand exactly how they intend to provide for communicating the required information to the rendering providers.


Who is Required to Consult the CDSM to Obtain the Required Approval?

The rule requires ordering physicians or his/her auxiliary personnel to consult an approved CDSM to obtain AUC. CMS defines auxiliary personnel as clinical staff under the direction of the ordering professional.  Accordingly, the ordering doctor can exercise his/her discretion in delegating the actual performance of the CDSM consultation with the understanding that the staff member must have sufficient clinical knowledge and the ability to interact with the qualified CDSM.

ADVOCATE is preparing educational materials for our clients to provide to their referring providers to help ensure that our clients will be provided with accurate and timely AUC information so that billing and reimbursement are not impacted.


In What Care Settings are AUC Consultations Required?

AUC requirements apply to advanced imaging services furnished in the following settings;

  • Ambulatory surgical centers
  • Outpatient settings (including office visits, hospital outpatient settings, and the emergency department – however exceptions are allowed for cases where there is a true emergency)
  • Independent diagnostic testing facilities (IDTF)

This requirement includes claim submissions for the professional, technical and global services.


Who is exempt?

CMS finalized the significant hardship criteria in the AUC program to include:

Insufficient internet access

Electronic health record (EHR) or clinical decision support mechanism (CDSM) vendor issues

Extreme and uncontrollable circumstances

These circumstances would be self-attested and reported to the furnishing professional, who would then append an appropriate modifier indicating that the ordering professional reported a significant hardship exception.


What’s next?

Through the rulemaking process, CMS invited the public to submit ideas on a possible methodology for the identification of outlier ordering professionals who would eventually be subject to the prior authorization process when ordering advanced diagnostic tests. The agency notes that it does not intend to use data during the education and operations testing period for determining outliers and as such, it expects to address outlier identification in 2022 or 2023 rulemaking.

ADVOCATE is preparing a detailed set of possible methodologies for the identification of outlier ordering professionals who would be subject to the prior authorization process when ordering advanced diagnostic tests. This step is important so that radiologists are not penalized for a lack of effort by the ordering physician.

For an in-dept look at the Clinical Decision Support Program, join us for a webinar on Wednesday, February 20th, 2019 at 10:00am EST. Please see registration details below.

As always, ADVOCATE will keep you up to date on this and all issues impacting radiology as they become available.


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