As this year’s election cycle has proven, making bold predictions this fall has turned out to be a bit of a crap shoot. In that vein, I thought I’d turn the fact checkers loose on my blog entry posted late last month regarding the rulemaking cycle for PAMA. So how accurately does the first blog entry reflect the Final Rule?
Claim: The deadline for providers to report interactions with AUC through a qCDSM would be January, 1 2018.
☑ The Final Rule confirms the 2018 deadline.
Claim: CMS would clarify that accessing the qCDSM would be required for each advanced imaging service.
☑ The Final Rule confirms that every advanced imaging order must consult the qCDSM.
The main difference between the Final Rule and the Proposed Rule is that the Final Rule creates the option for the ordering provider to “attest” that no applicable AUC were found in the qCDSM in addition to an automated response. That’s a slight change.
Our implementation guidance has not changed. A comprehensive set of imaging indications enables providers to select an indication for every advanced imaging order within the EMR. This ensures that providers are not flagged as outliers and that accurate payable claims are generated. CMS was emphatic in this year’s Final Rule that every advanced imaging service requires a consultation with a CDSM.
This comprehensive strategy ensures that the imaging decision support implementation can successfully support JACHO, CMS Hospital Compare, MACRA and other regulatory requirements.
Every day, we get questions from healthcare providers seeking to implement a successful decision support program that ensures compliance with the requirements of PAMA. I thought it would be helpful to address a few of the most important questions here.
How do the Priority Clinical Areas (PCA) inform mechanism requirements?
The point of the PCA is to provide a focus in terms of outlier measurement. In a sense, they do inform the “minimum” requirements in that the CDSM MUST contain AUC that cover the PCA. However, keep in mind that PAMA requires a mechanism access for every advanced imaging exam.
The claims process is not yet specified. A mechanism consultation equates to the selection/recording of an indication (as detailed in my first PAMA Blog) to confirm if the mechanism has AUC, recording that interaction and assigning a unique Decision Support Number.
There is language in the final rule regarding how this interaction is to take place, minimum requirements for CDSM, etc. For a CDSM to be approved it must reasonably represent that it at least has coverage of the PCA from more than one qPLE source (AUC publishers) and will have said AUC in time so that consultation can be reported as of Jan 1 2018.
NDSC’s solutions fully comply with the qCDSM requirements. Additionally, many qPLE have not yet published AUC, let alone to cover the PCA, so choosing a system without a complete set of AUC creates risk of both availability and/or coverage of the AUC. CareSelect Imaging incorporates AUC from all medical specialty society qPLEs to provide comprehensive indication coverage to cover the PCAs and beyond.
How do I ensure that claims are payable under PAMA?
The process to submit claims and measure outliers using this data has not yet been specified. The PCA have only been defined with enough specificity this round to inform mechanism producers and AUC publishers. We can expect more information in the next two rule making cycles.
We do know that both the Decision Support Number (DSN) generated by the CDSM, together with the indication, will be the cornerstone to the claims process. Limiting an implementation, specifically indication and AUC coverage at the front end, will risk proper claim formation.
I get lots of orders from the fax machine. How can I ensure these orders translate into payable claims?
The regulation is very clear about the requirement for the ordering provider to access the AUC and generate the evidence. It does not provide, nor endorse scenarios, for anyone besides the Ordering Professional to access to the qCDSM as a proxy.
NDSC has integrated its mechanism into all acute/ambulatory EMR applications. Our web portal, where providers can interact with the AUC, is also freely and widely available. This allows ordering providers to generate the Decision Support Number and Indication at the access point and ensure compliance.
Any other final thoughts?
It is tempting to interpret the final rule as a “specification”. In reality, it is a regulation designed to inform market implementations so there is flexibility to the extent that a workable system can be created. This said, I don’t see how a system can generate a payable claim, ensure providers are not outliers and have a system that is routine and accepted by ordering providers without implementing comprehensive indication coverage.