As a late addition to the “Protecting Access to Medicare Act” (PAMA) passed by Congress in 2014, the Centers for Medicare and Medicaid Services (CMS) has initiated the Appropriate Use Criteria (AUC) Program, which includes the Clinical Decision Support Mechanism (CDSM). The mandate requires ordering providers to consult an AUC software program when ordering advanced imaging tests and then issuing a certificate of compliance to the rendering provider so that they will be reimbursed by Medicare.
The AUC program was designed to support diagnosing physicians when they order advanced imaging tests, but, counterintuitively, impacts the rendering physician’s reimbursement if they don’t receive the certificate of compliance directly from the ordering provider. Eighteen months into the two-year education period and many ordering providers are unaware of the new mandate that takes effect beginning January 1, 2022.
For providers billing Medicare Part B, the impact on revenue could be significant. Radiology, cardiology, and orthopedic practices, as well as outpatient hospital facilities and imaging centers, will be reliant on ordering providers or stand to lose the revenue outright. The only exceptions will be for inpatient services (billing for Medicare Part A), emergency patients, and ordering physicians with significant hardship, such as rural locations or lack of accessible internet.
CDSM — what is it and how will it affect Medicare reimbursement?
For referring providers that order an advanced imaging test, including MRIs and CTs, the new mandate requires them to consult CMS-approved CDSM software with AUC to determine if the test is warranted. If so, the software generates and forwards a certificate of compliance and forwards it to the appropriate rendering provider.
The certificate is then held in the patient’s medical record with results codified on the outgoing imaging claim to Medicare. This mandate creates a unique situation where the ordering provider is responsible for the consultation, but the rendering provider is the one with reimbursement at risk.
What tests require an AUC consultation with the new mandate?
The following advanced imaging tests require CDSM:
- computed tomography (CT)
- magnetic resonance imaging (MRI)
- nuclear medicine, and
- positron emission tomography (PET)
When ordering advanced imaging tests for Medicare Part B patients, ordering providers will be required to consult with a CMS-qualified CDSM. Then the results of the AUC consultation will be forwarded to the rendering provider for inclusion on the Medicare reimbursement claim.
Does the new mandate have approved CDSM software or criteria?
Yes, CMS hand-selected a group of vendors to develop their own proprietary software to manage the AUC criteria and CDSM process. For each approved vendor, CMS worked with the AMA to issue company-specific G Codes for claim reimbursement purposes.
Will existing records systems be able to integrate with the new CDSM electronic portal?
Yes, specialties such as radiology, orthopedics, oncology, cardiology, sleep medicine, and others will require CMS-qualified CDSM software developed specifically for use with qualified provider lead entities (qPLEs) to assist in the diagnosis support. This CDSM Software will integrate seamlessly with existing EMR/EHR/RIS systems.
Are all primary and specialty providers impacted by this?
Any provider who uses advanced imaging technology to diagnose Medicare Part B patients should be in compliance with CDSM — including primary care, radiology, cardiology, oncology, sleep medicine, pain medicine, and orthopedics, among other specialties.
The only exclusions are for emergencies, inpatients requiring testing (Medicare Part A), and for providers that prove a hardship such as not having access to reliable internet services. There are new HCPCS Modifiers for each of these situations. Rendering providers will need to use the appropriate modifier on each claim to state their case.
For example, the modifier “MA” is used for any suspected or confirmed emergency where time didn’t allow for the use of the CDSM.
What happens if a Certificate of Compliance isn’t forwarded to the rendering provider?
Rendering providers will be required to comply with the CDSM mandate or risk the loss of revenue beginning January 1, 2022. While the CMS is choosing to focus on outreach and education at this time, there are plans to monitor and initiate consequences for those ordering providers that resist complying with the mandate in the future.
What does the furnishing provider’s advanced imaging claim need to include to demonstrate receipt of the compliance certificate?
These three values will be required on each claim:
- CPT G-codes that detail which CMS-approved CDSM software vendor was used,
- Similar to prior authorizations, there will be a unique consultation identifier number that will provide proof of a consult, and
- HCPCS modifier that will indicate whether the referral meets qPLE criteria or not. If the criteria indicate that the advanced imaging test is outside the scope of AUC, the ordering provider can proceed with the test but has to indicate on the Certificate of Compliance that their choice is outside CMS guidelines.
Will testing be reimbursed even if it doesn’t adhere to the AUC?
Yes, there is an HCPCS code that denotes the AUC was consulted. Rendering providers will be reimbursed for the procedure and the ordering provider may face monetary repercussions in the future if there is a defined pattern of non-compliance (as yet undetermined).
Are physicians prepared for the new CDSM mandate?
Whether unaware of the new mandate or reluctant to participate, many providers, both ordering and rendering are simply not prepared for January 2022. According to the American College of Radiology (ACR), it has fallen to rendering providers to provide education through outreach and professional education for their ordering physician base.
How can furnishing providers support ordering providers through this change?
Through advanced automation and machine learning, there is software that will ease the burden for both ordering and furnishing providers. The best option is a CDSM Solution from an approved vendor that offers the ability for furnishing providers to send a link to generate a CDSM consult to the ordering provider’s email. Then the ordering provider (or their designee) can generate the certificate and return a copy to the rendering provider in real-time.
Despite the massive information campaign spearheaded by CMS, many providers are unaware of CDSM and the new CMS mandate. Proactive radiology groups and hospital-supported outpatient systems have been providing outreach programs to educate ordering physicians in the use and importance of the new CDSM software options.
However, in the future, CMS may require non-compliant providers with a high rate of non-adherent procedures to get additional approval, such as prior authorizations, or face monetary risk.
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