The 2017 MPFS Final Rule
In 2014, Congress passed H.R. 4302, known colloquially 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.
This November, CMS released the 2017 Medicare Physician Fee Schedule (MPFS) final rule. This rule outlines the requirements for the creation of Clinical Decision Support programs for imaging – complete with definitions and time lines to ensure compliance for with PAMA.
- The Final Rule confirms the January 1st 2018 deadline to begin reporting on AUC interactions in order to receive payment for Medicare Advanced Imaging.
- The Final Rule defines a comprehensive implementation of a qCDSM. The ordering provider must consult a qCDSM by selecting an indication for every advanced imaging service.
- For each consultation, the qCDSM must record a unique Decision Support Number. This unique identifier connects the NPI, selected indication and service and the applicability of AUC to that order.
- Outliers will be measured against a set of Priority Clinical Areas and interaction with the AUC. This year’s rule defined an initial set of priority clinical areas, the scope of priority clinical areas will expand every year.
Key Terms and Definitions
The 2017 rule-making cycle defined two important terms:
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.”
Appropriate Use Criteria (AUC)
Appropriate Use Criteria (AUC) are guidelines created or endorsed by qPLE intended for use in decision support interactions. These guidelines form the backbone of knowledge that inform every decision support interaction. “AUC are defined 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.”
NDSC’s CareSelect Imaging™ also delivers locally authored AUC, or any published PLE criteria through the CareSelect™ localization tools.
This year’s rule also defined how the AUC, authored by qPLEs, are to be delivered through a qualified Clinical Decision Support Mechanism (qCDSM):
“CDSMs are the electronic portals through which clinicians would access the AUC during the patient workup.”3 NDSC’s CDSM, 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.
Note: CMS will publish a list of all qualified CDSMs in June 0f 2017
The PAMA Timeline
- Defined that only qualified Provider Led Entities (qPLE) can publish Appropriate Use Criteria 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).
- Established January 1, 2018 as the date by which sites must submit evidence of AUC consultation with their claims in order to receive payment.
- Confirmed that a Clinical Decision Support Mechanism must be consulted for every imaging order.
- Outlined the specifications for a “qualified CDSM”.
MPFS CY2018 & CY2019 Rule-Making Cycles
- 2018 Cycle will determine how evidence of consultation is to be submitted on claims for Medicare Advanced Imaging Services. 2019
- 2019 Cycle will define how Priority Clinical Areas will be used to determine outliers (physicians who consistently ignore AUC and will be subject to additional prior authorization.)
Implications for CDSM Implementation
A Comprehensive Implementation
A qCDSM must be consulted by the ordering provider for every Medicare advanced imaging exam in Outpatient and Emergency departments. The Act clearly specifies that AUC consultation is required for ordering professionals and does not provide for instances where consultation by furnishing professionals is an acceptable alternative, even if only to avoid claims denials.
A consultation is defined as 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. CDSM must record this interaction with the physicians NPI and then assign a unique Decision Support Number (DNS). CMS will define how the DSN will be used in the claims process in next year’s rule-making cycle.
Routine access to a structured, coded indication when ordering advanced imaging is required to ensure providers access the correct AUC and generate payable claims under the law.
Priority Clinical Areas – A Baseline for Coverage
CMS has defined Priority Clinical Areas. They are a tool to measure outliers. The PCA will expand year over year, and reduced AUC coverage within a CDSM will not reduce the requirement to consult and document a reason for exam. (See Above)
CMS has released diagnosis codes based on claims analysis that cover the PCAs. This release has been presented as “enough information” for CDSM producers to determine if they have AUC to provide adequate PCA coverage. The claims submission and outlier measurement process has not yet been defined – and will be defined only after the implementation deadline.
Providers will be measured against the PCAs for outlier measurement. The final list of priority clinical areas includes coronary artery disease (suspected or diagnosed), suspected pulmonary embolism, headache (traumatic and non-traumatic), hip pain, low back pain, shoulder pain (to include suspected rotator cuff injury), cancer of the lung (primary or metastatic, suspected or diagnosed), and cervical or neck pain.
Unlike the Medical Specialty Societies, many of the qPLE have not yet published or endorsed any AUC.
Avoiding Outlier Status and Ensuring a Payable Claim
To ensure that ordering providers have the best chance to avoid outlier status, and ensure that a claim is payable is to select and document a structured indication for every advanced imaging service. This requires a qCDSM with comprehensive indication coverage, and AUC that (minimally) comprehensively cover the indications associated with imaging within a priority clinical area.
If a CDSM has only a limited number of AUC and associated indications, or sparse indication coverage of a PCA, the workload on a provider increases as not only do the indications need to be searched, the fact that no AUC were found, and a reason why no AUC were found must be documented. This increases the risk to the ordering provider of being an outlier and the furnishing provider not having a payable claim.
The only way to remove this obstacle is to have a CDSM that has comprehensive indication coverage, where selection of a structured indication in the native EMR workflow is routine.
Recommended Implementation Timeline
With the January 1, 2018 date to begin reporting on AUC consultations 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.
|Before this date:||Your Organization Should do this:|
|April 1, 2017||Research and begin pricing CareSelect Imaging with ACR Select|
|June 1, 2017||Sign Contract|
|August 1, 2017||Begin your implementation — Schedule your implementation well in advance.|
|October 1, 2017||Plan to go live on or before this date with decision support functionality.|
NDSC CareSelect Imaging™ Implementation Guidance
CDSMs 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 CDSM they trust for their clients.
National Decision Support Company delivers a comprehensive set of structured indications and AUC from five of the provider led entities, including all medical specialty society AUC, rationalized into a single delivery platform enabling full compliance with all aspects of PAMA. Our comprehensive coverage ensures that providers find the correct clinical question for every advanced imaging exam, this ensure providers are accessing and viewing all required AUC, and ensure that a payable claim is always generated.
CareSelect Imaging™ uniquely includes ACR Select™, the most comprehensive set of published AUC covering all advanced imaging, including comprehensive coverage of the Priority AUC.
CareSelect Imaging™ is the preferred solution of major EMR vendors for compliance with PAMA. NDSC’s CDSM has provided over 20 million AUC consultations at over 1000 acute care facilities with over 100,000 physicians accessing our CDSM.