The contents of this document are intended to convey general information only and not to provide legal advice or opinions.
Updated: November 2018
The 2019 Medicare Physician Fee Schedule Final Rule
The Implementation Mandate
This year’s MPFS Rule – third of four rulemaking cycles – provides important implementation details related to the Appropriate Use Criteria (AUC) provisions of the Protecting Access to Medicare Act of 2014. Under the program, AUC consultations must occur across all applicable advanced imaging, and evidence of consultation must be included on all claims.
Program Start Date
January 1, 2020 remains the formal start of the program. From this date forward, healthcare providers must consult a qualified Clinical Decision Support Mechanism (qCDSM) when ordering advanced imaging tests furnished under Medicare Part B.
The program starts with a one-year “Educational and Operations Testing Period”. During this period, AUC consultation must occur across all advanced imaging and AUC consultation information is expected to be reported on claims, however claims will not be denied for failure to include proper AUC consultation information.
After the one-year period concludes, payment will be withheld for claims not correctly including consultation data and outlier physician calculation will begin.
Consultations by Ordering Professionals
To reduce the burden on Ordering Professionals (OP)*, CMS has clarified the personnel who can consult AUC at the time of order. This year’s rule formalizes the option for clinical staff, operating under the direct supervision of the OP to perform the consultation. Consultation must take place at the point of order and under the direction of the OP.
As the physician requesting the order is subject to outlier calculation, any workflows leveraging this option must ensure that the ordering physician is made aware of non-adherent requests at the point-of-order. This confirms the legislation’s focus on utilization management and emphasizes the educational impact of interactive AUC review when making care decisions.
Radiologists cannot consult. The statute distinguishes between ordering and furnishing professionals and indicates that OPs may have their staff, but not radiology staff, consult AUC on their behalf.
Independent Diagnostic Testing Facilities (IDTF) have been confirmed as an “Applicable Setting”. For any services furnished or ordered, an IDTF is now required to submit evidence of consultation for a payable claim.
CMS wants to ensure that as many Medicare services as possible are within scope for the program. Given the volume of Medicare Part B services furnished in standalone imaging centers, this expansion of coverage makes sense.
The expansion to include IDTFs raises the bar for these facilities to ensure the necessary infrastructure is in place for consultation and claims formation across all care settings. qCDSMs with web-based access points, like CareSelect Imaging, will be instrumental to enable these settings due to the diverse IT infrastructure.
Claims & Reporting
CMS has finalized the use of G-codes and modifiers to report the required AUC consultation information on the Medicare claim. The G-code will be used to define the qCDSM ID and CPT will be amended with HCPCS modifiers to indicate pertinent AUC consultation data.
To reduce the burden on providers of having to manually assign coding information, CDSMs must include G-codes and modifiers in their certification and documentation. Furnishing providers must include this consultation data on each claim but are not responsible for validating consultation information. When CareSelect is integrated into the EHR this process can be fully automated.
Qualified CDSMs will be assigned a G-code with a descriptor containing the name of the CDSM. If there is more than one advanced diagnostic imaging service on a claim, a single G-code will be attributed to all applicable imaging services.
CMS will accept consultation data with the following information:
- Information about which qCDSM was consulted by the ordering professional for the service.
- Information regarding—
- whether the service ordered adheres to the applicable appropriate use criteria;
- whether the service ordered does not adhere to such criteria; or
- whether such criteria is not applicable to the service ordered.
- The NPI of the ordering professional
We expect CMS to issue instructions early next year that will provide details as to the codes and method of submission as they did to inform those participating in the voluntary reporting period for PAMA starting in July of 2019. During the voluntary period, the modifier “QQ” can be used to modify CPT codes to indicate that a consultation has been performed for said service and the furnishing provider is aware of the result.
CMS has finalized three circumstances where ordering providers are not required to consult AUC.
These have been defined as:
- Emergency Services**
- If the service is furnished under Medicare Part A
This year’s final rule clarifies the proposed hardship exclusion and makes the ordering provider ‘self-report’ their exclusion from criteria. This year’s rulemaking finalized a definition for “Hardship”:
- Insufficient internet access.
- EHR or CDSM vendor issues
- Extreme and uncontrollable circumstances
These criteria add to the existing emergency services exclusion, where consultation is not required if it will cause undue harm to the patient.
This year’s rule finalizes the proposal for ordering professionals experiencing a significant hardship to self-attest and include that information on the order. The furnishing professional or facility would communicate on the Medicare claim for the service by appending a HCPCS modifier identifying the ordering professional’s self-attested significant hardship category.
Future Rule-making and Next Steps
Next year, CMS will undertake rulemaking to define how outliers are identified. Currently, outliers are defined as those providers who consistently do not adhere to AUC or fail to consult applicable AUC. Outliers will be penalized by being subject to additional authorization steps for Medicare Imaging services.
With this final rule, healthcare providers have all necessary information to begin implementation of a qCDSM. To prepare for the January 2020 deadline these implementations must begin as soon as possible.
We continue to work with key stakeholders, including CMS, our partners, and the market at large to develop a compliance framework that creates cost savings opportunities, assures full claims payment, and minimizes the chance of being flagged an outlier by making AUC that cover all advanced imaging available through CareSelect, our fully qualified CDSM.
Connect Compliance, Quality & Savings to Clinical Decision Support
CareSelect is the preferred qCDSM of all major EHR vendors. Our CareSelect Imaging solution delivers Appropriate Use Criteria (AUC) authored by leading medical specialty societies at the point-of-care. This empowers enterprise-wide quality improvement efforts and ensures compliance with PAMA AUC consultation requirements.
* The following roles are defined as Ordering Professional by the statute.
(i) A physician assistant, nurse practitioner, or clinical nurse specialist
(ii) A certified registered nurse anesthetist
(iii) A certified nurse-midwife
(iv) A clinical social worker
(v) A clinical psychologist
(vi) A registered dietitian or nutrition professional.
** Emergency Services have been defined in Section 1867 of the Social Security Act:
The term “emergency medical condition” means:
- a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in —
- placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy,
- serious impairment to bodily functions, or
- serious dysfunction of any bodily organ or part; or
- with respect to a pregnant woman who is having contractions —
- that there is inadequate time to affect a safe transfer to another hospital before delivery, or
- that transfer may pose a threat to the health or safety of the woman or the unborn child.