The Centers for Medicare and Medicaid Services is pushing back the starting date for a plan that would require physicians to use “appropriate use” criteria to order certain kinds of advanced diagnostic imaging.

In the Medicare Physician Fee Schedule and Quality Payment Program final rules for 2018 recently released by CMS, the agency said it was delaying the start of the program until 2020 to give the industry time to get used to the program.

The Medicare Appropriate Use Criteria (AUC) Program for Advanced Diagnostic Imaging was originally scheduled to begin in January, but organizations representing radiology professionals had been asking CMS to delay implementation, citing a lack of specifics for how the program would work and workflow challenges that healthcare organizations hadn’t ironed out.

Bloomberg file photo

The program, a form of clinical decision support, was established through the Protecting Access to Medicare Act of 2014, in which Congress included a mandate that providers consult appropriate use criteria via electronic clinical decision support systems when they order outpatient imaging exams for Medicare patients. Providers who conduct the imaging studies must document that consultation in order to receive reimbursement.

Under the program, CMS will review adherence to defined priority clinical areas—eight of which have been finalized—to identify outliers. The intent of the initiative is to aim to reduce diagnostic imaging expenditures by using industry-developed criteria to order studies. CMS will identify up to 5 percent of ordering providers as outliers and require them to obtain preauthorization when ordering imaging for Medicare patients.

In the final rules, CMS says 2020 will be an "educational and operations testing period," during which Medicare will pay all claims regardless of whether physicians record the correct AUC consultation information. While CMS delayed the mandatory deadline, the agency maintained a July 2018 start date for voluntary reporting of the codes—in this interim period, providers may use a single HCPCS modifier on claims to indicate that the ordering professional provided information on AUC consultation.

“During this time, CMS will collect limited information on Medicare claims to identify advanced imaging services for which consultation with appropriate use criteria took place,” the CMS announcement noted.

In addition, the AUC program has now has been formally aligned with the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which was signed into law in 2015 to create the Quality Payment Program that changes the way that Medicare rewards physicians.

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Physicians can use qualified clinical decision support mechanisms to earn credit under the Merit-Based Incentive Payment System as an improvement activity. An analysis from Advisory Board says that the CMS final rule formalizes the proposal to include AUC consultation using the clinical decision support rules “as a high-weight improvement activity. Ordering providers can earn 20 points out of the 40 needed for full credit in the ‘Improvement Activities’ category by demonstrating the use of CDS.”

Providers that achieve a minimum score in the Advancing Care Information category “have the opportunity to receive an additional 10-point bonus in that category for reporting CDS consultation as an improvement activity,” says Lea Halim, an analyst for Advisory Board.

Reimbursement denials are expected to begin in 2021 for furnishing providers that do not include required CDS information from claims.

Halim said the final rule also includes three areas of clarification for the program:

  • CMS has exempted Critical Access Hospitals from the CDS program, meaning that advanced imaging service furnished in CAHs do not require AUC consultation or reporting.
  • The agency did not provide any further information on the exemption for emergency services, which currently applies to emergency services provided to individuals with emergency medical conditions. More details on how these cases will be handled are expected in future rulemaking.
  • CMS also did not provide further information on how furnishing providers should handle updated or modified orders, but the agency acknowledged this issue and stated that it will be addressed in future rulemaking.

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