2020 seen as educational year for decision support for radiology

The federal program that will require the use of clinical decision support for prescribing outpatient radiological procedures will go through a year-long testing period.

The Centers for Medicare and Medicaid Services provided guidance late last week that claims will not be denied for failing to include codes that indicate that prescribing physicians sought guidance from formal clinical decision support mechanisms.

The pronouncement, issued as a Change Request by CMS to inform Medicare Administrative Contractors, provided some relief to radiologists and the healthcare industry by indicating that payments for eight “priority clinical areas,” won’t be negatively impacted during 2020.

That sets up the next calendar year as an educational and operations testing period, a term CMS used in its change order.

However, that order notes that CMS is expecting to expand the program to include consultation of guidelines for all advanced diagnostic imaging services, not just those deemed priority clinical areas.

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A technician looks at scanned imagery in the control room of the diagnostic imaging area at the Hong Kong Integrated Oncology Centre in Hong Kong, China, on Tuesday, Nov. 3, 2015. Equipped with biopsy facilities, body scanners, and quiet 'VIP' chemotherapy rooms, the Hong Kong Integrated Oncology Centre is the first of a string of such facilities that TE Asia Healthcare Partners, a portfolio company funded by TPG Capital, is planning in Asia. Photographer: Xaume Olleros/Bloomberg

The CMS program aims to enact the Protecting Access to Medicare Act, a portion of which seeks to increase the rate of appropriate advanced diagnostic imaging services—computed tomography, positron emission tomography, nuclear medicine and magnetic resonance imaging—for Medicare beneficiaries.

Under the program, when advanced imaging services are being ordered for a Medicare beneficiary, the clinician ordering the test must consult clinical decision support, “an interactive electronic tool for use by clinicians that communicates appropriate use criteria (AUC) information to the user and assists them in making the most appropriate treatment decision,” the change order noted.

The decision support mechanism will provide a code that must be included with the order for eight radiology services—coronary artery disease, suspected pulmonary embolism, headache, hip pain, low back pain, shoulder pain, cancer of the lung, and cervical or neck pain.

After Jan. 1, 2021, information on the ordering professional’s interaction with the clinical decision support tool, or an exception to the consultation, must be appended to the claim submitted by the radiological entity in order for it to be paid for providing imaging services.

While AUC-related information may not be consistently attached to imaging claims in 2020, CMS expects ordering professionals to begin consulting qualified CDS mechanisms, according to an analysis by Nathan Baugh, an associate with Capitol Associates, a government relations and consulting firm in Washington, in an analysis for the Association for Medical Imaging Management.

“CMS also released a significant amount of technical information regarding which advanced imaging codes are expected to have AUC consultations, the specific G-codes and modifier codes (for the result of the consultation),” Baugh wrote. “CMS created different modifier codes for the various exceptions to the AUC policy including: emergency medical conditions, insufficient internet access, electronic health record issues, extreme and uncontrollable circumstances.”

The complex program will hinge on the successful use of clinical decision support systems, expected to be embedded in providers’ electronic health records systems, and the transmission of proper coding to imaging professionals actually conducting those exams.

Ordering professionals who too frequently overrule guidance from systems on appropriate imaging exams risk being deemed as “outliers,” and may need prior authorization before ordering the tests for beneficiaries.

“While this CR did contain answers to some of our biggest questions, there are still aspects of the program that need clarification,” Baugh notes. “For instance, it is still unclear exactly where the ordering professional’s NPI should go on both the CMS-1450 (UB-04) and the CMS-1500 claim forms as well as their electronic equivalents. Moreover, it is still unclear how CMS expects us to report information from multiple ordering professionals using multiple qCDSM systems.

“CMS states that a subsequent CR will follow at a later date that will further operationalize the AUC policy,” he adds.

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