The contents of this document are intended to convey general information only and not to provide legal advice or opinions.
CY 2018 MPFS & QPP Final Rules
On March 26, 2014, Congress passed H.R. 4302, known colloquially as the Protecting Access to Medicare Act (PAMA). In it, Congress instructed the Centers for Medicare & Medicaid Services (CMS) to specify a program that requires physicians ordering certain imaging exams to consult with a qualified Clinical Decision Support Mechanism (CDSM) that relies on established Appropriate Use Criteria (AUC).
On April 16, 2015, Congress passed H.R.2, known colloquially as the Medicare Access and CHIP Reauthorization Act (MACRA). As part of MACRA, the Quality Payment Program established the Merit-Based Incentive Payment System (MIPS) to drive evidence-based and practice-specific quality improvement through a performance-based payment system.
On November 2, 2017, CMS published the CY 2018 Medicare Physician Fee Schedule (MPFS) and Quality Payment Program (QPP) Final Rules to revise PAMA and MACRA. These rules serve to align the qCDSM consultation requirements of the PAMA with the quality initiatives of MACRA and help to clarify the requirements for the creation of Clinical Decision Support (CDS) programs for compliant imaging AUC consultations.
CY 2018 QPP Final Rule
The CY 2018 QPP Final Rule defined two Finalized Improvement Activities targeted at early adopters of the Medicare AUC program – AUC Consultation through a qCDSM and Cost Display for Laboratory and Radiographic Orders. This allow early adopters to receive MIPS points in both the Improvement Activities and Advancing Care Information Performance Categories.
- AUC Consultation through a qCDSM is defined by CMS as a High-Weight Improvement Activity worth 20 points. In addition, AUC Consultation is also an eligible for a Advancing Care Information High-Weight Bonus.
- Cost Display for Laboratory and Radiographic Orders is defined as a Medium-Weight Improvement Activity worth 10 points. In addition, Cost Display is also eligible for a Advancing Care Information Medium-Weight Bonus.
Organizations that install NDSC’s CareSelect™ Imaging qCDSM prior to the 2018 MIPS reporting period and attest to qCDSM consultation will be eligible to receive MIPS points through both the “Improvement Activities” and “Advancing Care Information” Performance Categories.
The MIPS score will be used to calculate payment adjustments on a sliding scale from a 5% positive or 5% negative payment adjustment based on 2018 scores (paid in 2020) ramped up to +/- 9% scored in 2020 and paid in 2022. Payment adjustments will be on a linear scale, so every point earned will mean a larger reimbursement.
CY 2018 MPFS Final Rule
The CY 2018 MPFS Final Rule defined a formal start-date for the Medicare AUC Program and clarified details regarding the claims reporting process.
The CY 2018 MPFS Final Rule defined in regulation that as of January 1, 2020, all claims for Part B advanced imaging services must contain evidence of AUC consultation.
- The PAMA program starts with a voluntary reporting period from July 2018 – December 2019.
- Formal requirements for consultation and data submission will begin in January 2020 with a one-year “Educational and Testing” period.
- From January 2020, CMS will only pay claims if they have consultation information attached. An ordering provider must consult AUC forevery Medicare Part B advanced imaging order. Claims will require evidence of consultation to be paid. During this educational period consultation information will not be used to determine outliers but must be contained on the claim.
CMS has abandoned consultation reporting through G-Codes in favor of unique Decision Support Numbers (DSN). Utilizing a DSN simplifies the claims reporting process, allowing both sites and CMS to measure outcomes utilization and impact quality.
- Claims processing will require a “standardized unique identifier” or Decision Support Number (DSN)
It is our expectation that the information required for Medicare claims processing and, ultimately, identification of outlier ordering professionals, will be embedded within a standardized unique identifier. AUC adherence, non-adherence and not applicable responses should also be embedded. Therefore, we will not move forward with the creation of modifiers to identify each of those AUC consultation result conditions. We do expect that limited use of modifiers will be required in the future to identify certain exceptions to AUC consultation requirements.
Implications for a Compliant CDSM Implementation
A qCDSM must be consulted by the ordering provider for all Medicare Part B advanced imaging exams in the outpatient and emergency departments. A consultation is defined as the selection of an indication such that the mechanism can determine if it contains AUC for the service. A CDSM records which AUC applied to the service, and whether the service complied. If no applicable AUC exist, the provider must still select an indication and note that no applicable AUC exists.
PAMA clearly specifies that AUC consultation is required for ordering professionals and does not provide for instances where consultation by furnishing professionals or other clinical staff members is an acceptable alternative.
Recording and Reporting
Claims reporting is via Decision Support Number, which will be created to reflect the adherence, applicability and the CDSM consultation data. This identifier, when shared across care settings enables the consultation data to connect with the claims data. This data will be used by CMS to determine outliers and verify claims.
Avoiding Outlier Status
CMS has outlined 6 PCAs as a tool to measure outliers. PCA coverage will expand year over year and will be the baseline categories against which ordering providers are measured. The initial list of PCAs was published with the CY2017 Final Rule. The PCA are a minimum standard for qCDSM.
NDSC anticipates that outliers will be determined based on both adherence to AUC in the priority clinical areas, and applicability of the AUC to the service. Providers should select CDSM that contain AUC that cover their scope of practice.
Qualified does not mean Compliant
With the CY2018 Proposed Rule CMS published the list of all qualified Clinical Decision Support Mechanisms. There are two levels of qualification – Preliminary and Full. NDSC’s CareSelect Platform has been fully qualified for use to comply with the AUC provisions of PAMA and MACRA.
While NDSC is pleased to be “qualified”, this simply indicates that our technology meets a minimum standard, including AUC coverage of PCAs. This minimum standard does not consider the scope of practice for a provider. When considering a strategy for compliance, ensuring that AUC cover the full scope of practice is a critical decision point for caregivers when implementing a qCDSM.
The CareSelect Platform is the only fully qualified mechanism that offers no-fee access. This ensures that regardless of where the evidence of consultation needs to be created, or where a claim needs submission, caregivers can always access the required information to comply.
NDSC CareSelect™ Imaging Implementation
qCDSMs should be evaluated based on the quality and coverage of AUC and their capability to impact decision making across the enterprise. Your EMR vendor is the best source of information about which qCDSM they trust for their clients.
National Decision Support Company’s CareSelect Imaging solution delivers a comprehensive set of structured indications and AUC from five qPLE, including all medical specialty society AUC, rationalized into a single delivery platform. The foundational set of content for CareSelect Imaging is ACR Select™, the most comprehensive set of published AUC covering all advanced imaging, including comprehensive coverage of the PCA AUC.
Our comprehensive coverage ensures that providers find the correct clinical question for every advanced imaging exam. This ensures providers are consulting all required AUC and a payable claim is always generated.
CareSelect Imaging is the preferred CDSM solution of major EMR vendors, including Epic, Cerner, MEDITECH and Allscripts. NDSC’s qCDSM has provided over 30 million AUC consultations at over 500 health-systems, representing more than 2500 acute care facilities nationwide.
Recommended CareSelect Imaging Implementation Timeline
To receive your MIPS Improvement Activity Points and Advancing Care Information Bonus, you must implement and attest to using a qCDSM during the 2018 reporting period.
Our recommendation is that organizations interested in maximizing their MIPS Positive Payment Adjustment implement CareSelect Imaging by July 2018. An early implementation will ensure an immediate financial impact through the MIPS Performance Categories and set the stage for a compliant PAMA implementation.
MACRA | CY 2018 QPP Final Rule Update
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is a bipartisan legislation signed into law on April 16, 2015. MACRA created the Quality Payment Program that:
- Repeals the Sustainable Growth Rate formula
- Changes the way that Medicare rewards clinicians for value over volume
- Streamlines multiple quality programs under the new Merit Based Incentive Payments System (MIPS)
- Gives bonus payments for participation in eligible alternative payment models (APMs)
The CY 2018 Quality Payment Program Final Rule aligned the AUC requirements of PAMA with the quality improvement initiatives of MACRA. NDSC’s CareSelect Imaging solution includes capabilities that address high-priority Quality and Practice Improvement measures for imaging and beyond.
MIPS Performance Categories
Early adopters of the Medicare AUC program are eligible to receive points in two MIPS Performance Categories – Improvement Activities and Advancing Care Information. In addition, qCDSM consultation combined with targeted clinical interventions can apply to the Quality and Cost Performance Categories.
Finalized Improvement Activities:
AUC Consultation through a qCDSM is defined by CMS as a High-Weight Improvement Activity worth 20 MIPS points.
Cost Display for Laboratory and Radiographic Orders is defined as a Medium-Weight Improvement Activity worth 10 MIPS points.
Advancing Care Information Bonus:
AUC Consultation through a qCDSM is eligible for a Advancing Care Information High-Weight Bonus.
Cost Display for Laboratory and Radiographic Orders is eligible for a Advancing Care Information Medium-Weight Bonus.
Quality & Cost Improvement
CareSelect Imaging delivers advanced decision support, incorporating patient assessment tools such as Pediatric Head Trauma (PECARN) or Adult Head Trauma (GCS calculators), and medication information into its decision support algorithms. Aligning the intervention with the measure.
Our implementations can be tuned to enable focused, condition based interventions and reporting that link to high-priority MIPS measures (or other targets). Qualified mechanisms will be able to provide a report to the ordering clinician that can be used to assess patterns of image-ordering and improve upon those patterns to ensure that patients are receiving the most appropriate imaging for their individual condition.
PAMA | CY 2018 MPFS Final Rule Update
The Protecting Access to Medicare Act requires physicians ordering certain imaging exams to consult with a qualified Clinical Decision Support Mechanism (CDSM) that relies on established Appropriate Use Criteria (AUC).
PAMA applies to all Medicare Part B Advanced Diagnostic Imaging Services (CT, MR, NM, PET) in the Outpatient and Emergency departments. All advanced imaging exams furnished and paid under Medicare Part B must show display evidence of AUC consultation through a qCDSM to make a payable claim. While PCAs will contribute to the determination of “Outlier Status”, they do not restrict the need for comprehensive AUC coverage for CDSM consultation.
Claims for furnished services covered by Medicare Part B, the hospital outpatient services and ambulatory surgery center payment models all require evidence of qCDSM consultation to be payable.
Exemptions to Consultation
The CY2017 Final Rule established that exceptions to the consultation requirement existed when:
- For Emergency Services, provided to patients with emergency medical conditions
- Inpatient services where payment is made under Medicare Part A
- Significant hardships
The CY2018 Proposed Rule hardship exemptions have not been finalized.
In response to public comments that varied widely, CMS decided not to finalize the proposed changes to the significant hardship exceptions in this final MPFS rule. The agency will take time to consider both the public comments on the proposals and the policies adopted in the CY 2018 QPP final rule and will revisit the issue in rulemaking for CY 2019.
We anticipate that any hardship exemptions will align with other quality programs. We do not expect an exemption to the consultation requirement if there is reasonable access to a CDSM (EHR integrated or no-fee).
Critical Access Hospitals are not defined as an applicable setting
Any advanced imaging service furnished within a CAH would not be furnished in an applicable setting. Applicable settings currently include physician offices, hospital outpatient departments and ambulatory surgical centers. CAH patients who are furnished an advanced diagnostic imaging service in an applicable setting but the claim for that imaging service is not paid under one of the applicable payment systems would not require consultation and reporting of the AUC consultation. This may apply in situations when a CAH has elected Method II billing
The PAMA Rulemaking Timeline
MPFS CY2016 Final Rule
Defined that only qPLE can publish AUC for use in compliant decisions support consultations.
Established initial list of PLEs including the American College of Radiology (ACR), the National Comprehensive Cancer Care Network (NCCN) and the American College of Cardiology (ACC).
MPFS CY2017 Final Rule
Confirmed that a CDSM must be consulted by the ordering professional for every imaging order.
Finalized initial list of Priority Clinical Areas (PCAs) to provide a baseline for AUC coverage.
Outlined the specifications for a “qualified CDSM”.
MPFS CY2018 Final Rule
Established a voluntary reporting period beginning on July 1, 2018. This will allow organizations already equipped with a CDSM to begin reporting. It is important to note that physicians can earn Merit Based Incentive Payment System (MIPS) credit for consulting AUC through a qCDSM beginning on January 1, 2018 MIPS reporting period under MACRA.
Established that as of January 1, 2020 ordering providers must consult and furnishing providers must report on AUC consultation information on claims.
For a period of one year, the claims data will not be required to be accurately formed, but must be included. This period will be used for education and testing.
Established that the unique consultation identifier, or Decision Support Number (DSN) that will form the basis of claims reporting. This effectively connects the data captured by the CDSM at consultation with the claims data generated when the service is furnished.
MPFS CY2019 Rule-Making Cycle – Coming Soon
The CY2019 Cycle will define how PCAs will be used to determine outliers – physicians who consistently ignore AUC and who will be subject to additional prior authorization requirements.