The contents of this document are intended to convey general information only and not to provide legal advice or opinions.
Updated: July 2018
This Year’s MPFS Proposed Rule
January 1, 2020 – The Implementation Mandate
This year’s MPFS Proposed Rule (the third of four rulemaking cycles) provides important implementation details related to the AUC provisions of the Protecting Access to Medicare Act of 2014. The rule will be finalized in November 2018 after a stakeholder comment period.
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. Under the program, consultations must occur across all advanced imaging, and evidence of consultation must be included on all claims.
The first year of the program is defined as an “Educational and Operational Testing Period”. During this period, qCDSM consultations must occur and providers must submit evidence of the consultation for all applicable advanced imaging orders. It is anticipated that all claims must contain consultation data, however, payment will not be withheld for incorrectly formatted claims. After the one-year period concludes, payment will be withheld for claims not correctly including consultation data and outlier physician calculation will begin.
Program Start Date
January 1, 2020 remains the formal start of the program. From that date forward, healthcare providers must consult a qualified CDSM 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 evidence of consultation must be included on the claim. Incorrectly formed evidence will not result in payment being withheld.
CMS has proposed to expand the personnel who can consult AUC at the time of order. In many organizations, proxies will often place orders on behalf of physician. This year’s rule formalizes the option for these proxies, while operating under the supervision of the ordering provider, to perform the consultation.
As the provider requesting the order is subject to outlier calculation, any workflows leveraging this option must ensure that the ordering provider is made aware of non-adherent requests at the point-of-order. While this workflow option accommodates pre-existing order entry workflows, it also requires in-depth EHR integration knowledge to effectively implement.
Consultation must take place at the time of order and under the supervision of the ordering provider. It is important to remember that this legislation focuses on the use of evidence-based AUC to manage utilization during the order entry process and emphasizes the educational impact of interactive AUC review when making care decisions.
The statute distinguishes between the ordering and furnishing professional, recognizing that the professional who orders an applicable imaging service is usually not the same professional who bills Medicare for that service when furnished.
We interpret this to mean that ordering providers may have their staff (but not radiology staff) consult AUC on their behalf.
Independent Diagnostic Testing Facilities (IDTF) have been added 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.
This expansion to include IDTFs raises the bar for providers of these services and operators of 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, including CareSelect Imaging, will be instrumental to enable these settings due to the diverse IT infrastructure.
Claims & Reporting
CMS will accept all consultation data, as defined by the regulation, in the form of G-Codes with HCPS modifiers. The defined information is as follows:
- 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
In addition, the qCDSM must produce a Unique Consultation Identifier or Decision Support Number (DSN). This DSN readily connects the consultation to claim, particularly when the ordering and furnishing facilities are disparate domains. Although the proposed rule suggests that the DSN is not required for claims purposes, the DSN is required to connect the consultation and claims data. This ensures protection against future audit, as the qCDSM must retain this information for 6 years.
We expect CMS to issue a transmittal 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 outlined 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 proposed rule clarifies the proposed hardship exclusion and makes the ordering provider ‘self-report’ their exclusion from criteria. This year’s rulemaking proposed 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.
*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.
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 rulemaking cycle, 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.