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Is Your Organization Ready for Advanced Imaging Clinical Decision Support in 2020?

Is your Organization Ready for Imaging Clinical Decision Support in 2020?

The Protecting Access to Medicare Act (PAMA) was signed into law in April of 2014.As part of the legislation, under section 218b, providers will now have to consult appropriate use criteria when ordering advanced imagining exams for Medicare Part B beneficiaries.

Advanced imaging exams that are included are: computed tomography (CT), magnetic resonance imaging (MRI), nuclear medicine, and positron emission tomography (PET) scans.

What to expect

Physicians ordering the advanced imaging exams will have to go to the computer to consult a government-approved, evidence-based appropriate-use criteria (AUC). The clinical decision support (CDS) software will analyze and rank the appropriateness of a physician order for the exam. Physicians furnishing the advanced imaging services will only be paid if claims confirm the AUC was consulted, which software was used and whether the exam ordered adhered or did not adhere to an acceptable clinical decision rating.

Consultation of AUC is required prior to ordering the advanced diagnostic imaging services. The CDS mechanism provides a determination of whether the order adheres to AUC of if it is not applicable.

This program impacts ALL physicians and practitioners that order advanced diagnostic imaging services as well as the physicians, practitioners that furnish the advanced order imaging to Medicare Part B beneficiaries.

Program Timeline

  • July-December 2019 - Voluntary Report Period - Furnishing providers can report consultation of AUC using HCPCS modifier QQ -Ordering providers using CDS can receive credit in two MIPS categories.
  • January 2020 - Education open testing period - Ordering providers must consult AUC through qualified CDS mechanism (CDSM) - Furnishing providers must document consultation on the claim but no reimbursement at risk.
  • January 2021 - Start date - payment at risk - Reimbursement denials expected to begin for furnishing providers not documenting AUC consultation.
  • January 2023-2024 - Outliers identified.

Beginning January 1, 2020, a provider must use a qualified CDSM and report appropriate use criteria consultation information on the professional and facility claims for service. The claims will include:

  • The ordering professional's NPI.
  • Which CDSM was consulted such as R-scan created by the College of Radiology.
  • Whether the service ordered would or would not adhere to consulted appropriate use criteria or whether it was not applicable to the service ordered.

CMS has determined the following exceptions to the reporting requirements

Emergency services when provided with certain medical conditions, inpatients and for which Medicare Part A payment is made and ordering professionals when experiencing significant hardship such as insufficient internet.

What your office needs to do now

  • It is important to begin taking steps to become prepared for this new law.
  • Familiarize your office with clinical decision support mechanisms.
  • Begin using the software for ordering the advanced imaging tests.
  • Prepare your office to adopt the clinical decision support mechanisms for ordering and appropriate use.
  • Discuss imaging appropriateness with patients and make decisions together.
  • Work with the EHR implementation to integrate clinical support technology.

While this may be for Medicare patients only, it's important to note that as Medicare goes so does the rest of the industry.

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