CY 2018 MPFS Proposed Rule Update
In 2014, Congress passed H.R. 4302, also known as the Protecting Access to Medicare Act of 2014 (PAMA). In it, Congress instructed the Centers for Medicare & Medicaid Services (CMS) to specify a program which will require physicians to consult with a qualified Clinical Decision Support Mechanism (qCDSM) that relies on established Appropriate Use Criteria (AUC) when ordering certain imaging exams.
On July 13th, 2017, CMS released the 2018 Medicare Physician Fee Schedule (MPFS) proposed rule. The third rule in a 4-year cycle, the CY2018 Proposed Rule helps to clarify the requirements for the creation of Clinical Decision Support (CDS) programs for imaging and guide compliant AUC consultations.
Key Terms and Definitions
Appropriate Use Criteria (AUC)
Appropriate Use Criteria (AUC) are clinical guidelines intended for use in decision support interactions. These guidelines form the backbone of knowledge that inform every decision support interaction. CMS defines AUC as “criteria that are evidence-based (to the extent feasible) and assist professionals who order and furnish applicable imaging services to make the most appropriate treatment decisions for a specific clinical condition.” AUC are authored organizations approved by CMS as qualified Provider-Led Entities (qPLE).
Qualified Provider Led Entity (qPLE)
A qualified Provider-led entity (qPLE) is responsible for the creation of sets of AUC for use in CDS interactions. Each organization approved to create or endorse AUC follows strict guidelines and rules for criteria authoring. CMS defines a qPLE as a “national professional medical specialty society or other organization that is comprised primarily of providers or practitioners who, either within the organization or outside of the organization, predominantly provide direct patient care.”
Qualified Clinical Decision Support Mechanism (qCDSM)
CDSMs are the electronic portals through which a clinician accesses AUC during the patient workup. NDSC’s qCDSM, CareSelect Imaging™, automatically incorporates information such as specific patient characteristics, laboratory results, and lists of co-morbid diseases from Electronic Health Records (EHRs) and other sources. With a fully embedded CDS platform, practitioners interact directly with the CDSM through their primary user interface, minimizing interruption to the clinical workflow.
Priority Clinical Areas (PCAs)
In the CY2017 MPFS Final Rule, CMS published an initial list of Priority Clinical Areas (PCAs). PCAs are a minimum standard for AUC to be delivered by qCDSM, and will be used, in part as a baseline by CMS to measure clinicians for “Outlier Status”. Clinicians who fall into the “Outlier” category will be burned with additional Prior-Authorization requirements to place advanced imaging orders. PCAs currently cover approximately 40% of advanced imaging exams ordered under Medicare Part B and will expand with each calendar year going forward.
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.
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 exceptions have been proposed as follows:
- Hardship exemption applies to OP who are granted a “re-weighting” of their Advancing Care Information MACRA performance category to zero percent of the final score under MIPS for the year.
- Providers who have insufficient internet connectivity, or have extreme and uncontrollable circumstances.
- Lack of availability of CEHRT (only applies to ordering provider)
- Lack of Face to Face Patient interaction.
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 Proposed Rule
- Proposed a voluntary reporting period beginning on January 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 under MACRA.
- Proposed an “educational and operations testing period” beginning on January 1, 2019. During this period, all organizations must report on CDSM consultations. During this period, ordering professionals would consult AUC and furnishing providers would report AUC consultation information on the claim.
- Established initial list of qualified Clinical Decision Support Mechanisms (qCDSM) and expanded the list of qualified Provider-Led Entities (qPLE).
MPFS CY2019 Rule-Making Cycle
- 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.
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 G-Codes, which will be created to reflect the adherence, applicability and the CDSM consultation data. This data will be used by CMS to determine outliers.
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.
Qualified does not mean Compliant
With the CY2018 Proposed Rule CMS published the list of qCDSM. 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 the AUC and indication coverage. 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 Implementation Timeline
The January 1, 2019 date to begin reporting on AUC consultations is approaching quickly. Your organization needs to be proactive and begin planning to implement Imaging decision support as soon as possible. The table below can serve as a general guide to keep your implementation on track.