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The CY 2018 MPFS & QPP Final Rules
What You Need to Know

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CMS recently published the CY 2018 Medicare Physician Fee Schedule (MPFS) and Quality Payment Program (QPP) Final Rules. Both rules include updates regarding the requirements for Appropriate Use Criteria (AUC) consultation when ordering Medicare Fee for Service Advanced Imaging exams and formally align the goals of PAMA and MACRA.

A Formal Alignment of PAMA and MACRA

The CY2018 MPFS Final Rule answered one fundamental question – “Is CMS serious about implementing Section 218b of PAMA?” – with a resounding “YES”. Furthermore, CMS clarified that the goals of the Quality Payment Program, also known as MACRA, are the result of separate yet associated statutory requirements. Rather than merge the programs, as many advocated, CMS exercised their statutory authority to formally align the programs.

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.

This alignment will create immediate financial impact through a Positive Payment Adjustment and set the stage for a compliant and accurate PAMA implementation.

NDSC’s CareSelect Platform enables organizations to align their imaging and enterprise CDS programs to target improvement activities in high priority MACRA measures. Targeted interventions in imaging, lab studies, blood management and other service lines can improve MIPS Quality Scores and build on the Advancing Care Information Bonus to maximize the positive payment adjustment.

Final Rule Fast Facts

• The CY 2018 Quality Payment Program (QPP) Final Rule defined that early adopters will receive a bonus on their Advancing Care Information MIPS Score if they attest to the consultation of a qualified Clinical Decision Support Mechanism during the 2018 MIPS reporting period.

• Claims for Medicare Part B Advanced Imaging Services will only be payable if they contain accurately formed evidence of the ordering provider’s consultation.

• CMS is implementing requirements for Ordering Providers to consult with Appropriate Use Criteria (AUC) as an alternative means to traditional forms of prior authorizations.

• 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.

Read Our Full CY 2018 Final Rule Write-Up

A Compliant Implementation

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 include the necessary evidence of consultation. An ordering provider must consult AUC for every Medicare Part B advanced imaging order. Each claim will require evidence of consultation to be paid. During this educational period consultation information will not be used to determine outliers.

The timeline as outlined in the MPFS Final Rule allows organizations the required time to implement with a more thoughtful approach. The voluntary reporting period allows time for organizations to verify the accuracy of reported claims data to ensure payment in preparation for the January 2020 date and receive credit towards their MACRA score.

Questions on Claims & Reporting

In July’s MPFS proposed rule, CMS outlined an approach whereby G-Codes and HCPCS modifiers would be used to report consultation information on claims. This approach did not adequately connect the data generated at the encounter (consultation) with the data generated at the claim (furnished service).

Although CMS did not provide specific details regarding how claims will be formed. They did indicate that the Decision Support Number (DSN) generated by the mechanism will be the foundation for their approach. This information enables sites to plan order-entry and furnishing workflows that ensure the incorporation of consultation data.

In the recent Final Rule, CMS abandoned the G-Code approach in favor of a significantly less burdensome approach that will use Unique Decision Support Number (DSN). Utilizing a DSN simplifies the claims reporting process, allowing both sites and CMS to measure outcomes utilization and impact quality.

Learn More

We’ve updated our PAMA & MACRA page with all the details. We’ve also added extensive information about how we link to the provisions of MACRA. We’ll be updating all our regulatory resources on a regular basis as we get details from CMS

MACRA, a qCDSM and the Value-Based Payment Modifier

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CMS recently proposed that healthcare providers on the MIPS payment track who attest to consulting a qualified CDSM across all advanced imaging orders in 2018 will receive credit towards their practice improvement activity. When integrated with a CEHRT, they can receive an additional Advancing-Care information score.

During 2018, the “cost” category score will also contribute to future payment adjustments. The cost component of MACRA will be calculated based on the overall Medicare Spend-per-Beneficiary using the Value Based Payment Modifier. A better score translates to more payment.

When considering a PAMA compliance strategy, managing utilization across all Medicare services will become increasingly important.  A qCDSM with comprehensive AUC coverage and capabilities that impact utilization across all care settings, including pediatrics, becomes more important than ever.

CMS is telegraphing a stronger linkage between MACRA and the AUC provisions of PAMA. Further reinforcing the need for healthcare organizations to manage the overall utilization of services covered by Medicare using decision support tools in 2018.

Keep Reading:

From the NDSC Blog:
The CY2018 Medicare Physician Fee Schedule (MPFS) Proposed Rule – The Upshot
PAMA and MACRA – A Surprising Twist

From the Quality Payment Program:
QPP Proposed Rule Summary
Quality Payment Program Homepage

The CY2018 Medicare Physician Fee Schedule (MPFS) Proposed Rule – The Upshot

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Not surprisingly, this year’s rulemaking cycle proposes to delay the implementation of the Protecting Access to Medicare Act (PAMA) to January of 2019. The additional time will allow healthcare providers to implement the claims reporting requirements as detailed in the proposed rule and for CMS to implement the required changes in the claims process.

The team at NDSC is developing our summary of the rule and will be updating our customers over the next several weeks. What’s important about this rulemaking cycle is not what’s in the rule, but what is not.

What’s still missing is how CMS intends to flag ordering providers as outliers. Providers need to be aware that both adherence to the Appropriate Use Criteria (AUC) within the Priority Clinical Areas and the applicability of the AUC to their scope of practice are opportunities for CMS to flag providers as outliers. Adherence to and applicability of the AUC are both in scope for outlier calculation.

CMS reiterated a comprehensive consultation requirement, requiring evidence of consultation to be generated for every advanced diagnostic imaging service paid for under Medicare Part B. This comprehensive consultation requirement translates to comprehensive measurement. qCDSMs must report not only on adherence to AUC, but also applicability of the AUC to the service.

Healthcare organizations and caregivers must position themselves not only to comply, but implement a solution that assures that their caregivers are best positioned to avoid the additional burden of prior authorization implied by the statute.

The Upshot

If an organization implements a CDSM that does not deliver AUC to cover the providers’ full scope of practice, many consultations will not yield applicable AUC. This increases the risk that the providers will be subject to the additional burden of prior authorization for Medicare beneficiaries. Again, adherence to and applicability of the AUC are both in scope for this calculation.

The reporting requirements outlined in rulemaking are a subset of the data that the qCDSM must record. Combined with the requirement that qCDSM must store data for 6 years, we can expect that the data recorded in the mechanism to be subject to audit.

While NDSC is pleased to be “qualified”, this qualification 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.

We also believe that it is critical for caregivers to have easy access to 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.

As an organization, NDSC is qualified. We’ve integrated our qCDSM into every major EMR platform on the market, and have the most comprehensive AUC libraries at our disposal. Healthcare providers at over 300 healthcare organizations, covering over 2500 facilities trust our system to guide their imaging choices over 3 million times a month. CareSelect™ is a fully qualified mechanism, backed by a fully qualified organization.

For the 2018 MIPS performance period, CMS added a new improvement activity that MIPS eligible clinicians could choose if they attest they’re using AUC through a qualified clinical decision support mechanism for all advanced diagnostic imaging services ordered.

Additional coverage from the ACR: American College of Radiology’s Proposed Rule Summary

PAMA and MACRA – A Surprising Twist

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In the recent proposed rule for year two of The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the Centers for Medicare and Medicaid Services (CMS) have introduced a surprising twist – linking the Protecting Access to Medicare Act (PAMA) to MACRA.

Tucked away on page 178 of the proposed rule is a new improvement activity linked to the Advancing Care Performance Category. This improvement activity allows organizations who have implemented a qualified Clinical Decision Support Mechanism (qCDSM) to receive credit in this category:

A MIPS eligible clinician would attest that they are consulting specified applicable appropriate use criteria (AUC) through a qualified clinical decision support mechanism for all advanced diagnostic imaging services ordered. This activity is for clinicians that are early adopters of the Medicare AUC program (e.g., 2018 performance year) and for clinicians that begin the program in future years as will be required by CFR §414.94 (authorized by the Protecting Access to Medicare Act of 2014). 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.

This development provides some tantalizing useful and important insight into the PAMA regulatory process:

  1. Providers must attest to consulting the qCDSM across all advanced imaging. We recognize that CMS has yet to publish the anticipated 3rd MPFS proposed rule; however this should clear up any mystery about limiting consultations to just the 8 Priority Clinical Areas (PCA). NDSC’s interpretation has always been that all advanced imaging orders require a consultation of applicable AUC, not just the PCAs.
  2. Our interpretation is that the timing for PAMA will now align with the first MACRA payment adjustment. CMS is rewarding providers who have or are currently adopting AUC based on CMS’ guidance that starting Jan 1 2018, claims for Medicare Part B advanced imaging services require evidence of a qCDSM consultation.

In short, the country’s largest payer now requires consultation with a qCDSM across all advanced imaging services. This is certain to have implications for traditional utilization management approaches that rely on prior authorization through third parties.

Useful Links: MACRA Proposed Rule Fact Sheet

Walking Paper

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A Walking OrderImaging orders flow to furnishing sites in a variety of ways. Too often, these orders are “sent” via the patient, who leaves the caregivers office with a piece of paper. We get a lot of questions about how to manage walking paper, including orders via email and the trusty fax machine, with consideration of the new PAMA requirements. Here is our solution.

A PAMA Refresher

The central requirement of the Protecting Access to Medicare Act of 2014 requires that caregivers who order advanced imaging tests provide evidence of consultation of a Clinical Decision Support Mechanism (qCDSM). The qCDSM must leverage Appropriate Use Criteria (AUC) from a qualified Provider Led Entity (qPLE).

Consultation with AUC when placing imaging orders is proven to reduce inappropriate utilization, and the consultation requirements for Medicare Part B advanced imaging services introduced by CMS replace the need for prior authorization of these services.

Countless paper orders are generated in the ambulatory setting when ordering or furnishing advanced imaging. The caregiver is required by law to consult AUC, and the furnishing provider must submit evidence of said consultation with the claim to receive payment.

Access is critical

The answer to most of the questions lies with access. As the law does not provide for a “proxy” consultation, widespread access to a CDSM for caregivers in the ambulatory setting is central to compliance with the program. Furnishing providers are rightfully concerned about generating a payable claim.

For caregivers in the ambulatory setting that frequently order advanced imaging, EMR integration makes access to the CDSM easy, routine and automatic. Integration ensures that the order will always contain the required evidence of consultation, whether sent electronically or printed. The paper simply needs to contain the unique transaction identifier called a Decision Support Number (DSN). This DSN links the order to all the needed claims data.

To ensure widespread access in the ambulatory setting, where services are ordered but not furnished, NDSC now offers a complimentary version of our CDSM known as ACR Select™ Basic. ACR Select Basic is available within numerous ambulatory EMRs in widespread market use. This ensures that caregivers are always able to consult a CDSM when needed.

For Caregivers who infrequently order advanced imaging, or do not have integrated EMR access, we offer a complimentary web site that can generate evidence of a consultation for compliance with PAMA.

Practically speaking, when a furnishing site receives a fax or a piece of paper with a DSN, they can easily access the data associated with a consultation and guarantee that the claim is payable.

We recommend to furnishing sites to adapt their business process and policy associated with furnishing Medicare Part B advanced imaging orders to include awareness and education regarding the availability of this free resource to the ordering provider in the event an order is received without the required evidence.

Beyond Compliance
Prescription Pad - Beyond Compliance

When paper walks, determining why the imaging exam was selected often requires phone calls, exchange of notes, and a lot of frustration. Often, when the patient arrives, they don’t know why or where imaging is needed.

Then there’s the matter of payment. Once the ambulatory imaging provider does determine why the exam is needed, a similar process of phone calls and faxes starts with the payer. This is not generally a doctor to doctor exchange.  Doctors are busy enough, so administrative staff fill in.

As our population ages, the range and specificity of medical testing options are only increasing. Insurance companies continue to “guide” care and selecting the right tests to ensure the correct outcome can be a challenge.  It’s not getting any easier for either side of the imaging chain to navigate this new landscape. Survival is no longer about just doing “more”. Instead, it is about doing more of the right thing and a renewed focus on the patient.

Email Decision Support NumberThe solution starts with the ordering provider asking a clear, clinical question to answer through imaging that the furnishing imaging provider can understand. When linked to a DSN, that indication can flow from order all the way through billing.

The communication of clear, structured data across sites of care, whether on a piece of paper or embedded within an electronic message delivered through our CareSelect™ solution unleashes a slew of possibilities.

Medicare Part B services are effectively authorized by qCDSM consultation. Across every use case, paper is reduced, more appropriate services are ordered, and furnishing sites receive better information.

CareSelect Imaging delivers multiple AUC sets to provide not only the most appropriate test for PAMA compliance, but to incorporate payer criteria and enable providers to leverage our technology to reduce the administrative burden of the prior authorization process through automation.

Interested in Learning More About PAMA?

 

Join our PAMA webinar featuring Erin Lane from the Advisory Board Company on March 9th.

 

Want to learn more about our CareSelect™ platform?

REACH OUT TODAY

A PAMA Consultation – Revisited

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As this year’s election cycle has proven, making bold predictions this fall has turned out to be a bit of a crap shoot. In that vein, I thought I’d turn the fact checkers loose on my blog entry posted late last month regarding the rulemaking cycle for PAMA. So how accurately does the first blog entry reflect the Final Rule?

Claim: The deadline for providers to report interactions with AUC through a qCDSM would be January, 1 2018.

☑   The Final Rule confirms the 2018 deadline.

Claim: CMS would clarify that accessing the qCDSM would be required for each advanced imaging service.

☑   The Final Rule confirms that every advanced imaging order must consult the qCDSM.

The main difference between the Final Rule and the Proposed Rule is that the Final Rule creates the option for the ordering provider to “attest” that no applicable AUC were found in the qCDSM in addition to an automated response. That’s a slight change.

Our implementation guidance has not changed. A comprehensive set of imaging indications enables providers to select an indication for every advanced imaging order within the EMR. This ensures that providers are not flagged as outliers and that accurate payable claims are generated. CMS was emphatic in this year’s Final Rule that every advanced imaging service requires a consultation with a CDSM.

This comprehensive strategy ensures that the imaging decision support implementation can successfully support JACHO, CMS Hospital Compare, MACRA and other regulatory requirements.

Every day, we get questions from healthcare providers seeking to implement a successful decision support program that ensures compliance with the requirements of PAMA. I thought it would be helpful to address a few of the most important questions here.

How do the Priority Clinical Areas (PCA) inform mechanism requirements?

The point of the PCA is to provide a focus in terms of outlier measurement. In a sense, they do inform the “minimum” requirements in that the CDSM MUST contain AUC that cover the PCA. However, keep in mind that PAMA requires a mechanism access for every advanced imaging exam.

The claims process is not yet specified. A mechanism consultation equates to the selection/recording of an indication (as detailed in my first PAMA Blog) to confirm if the mechanism has AUC, recording that interaction and assigning a unique Decision Support Number.

There is language in the final rule regarding how this interaction is to take place, minimum requirements for CDSM, etc. For a CDSM to be approved it must reasonably represent that it at least has coverage of the PCA from more than one qPLE source (AUC publishers) and will have said AUC in time so that consultation can be reported as of Jan 1 2018.

NDSC’s solutions fully comply with the qCDSM requirements. Additionally, many qPLE have not yet published AUC, let alone to cover the PCA, so choosing a system without a complete set of AUC creates risk of both availability and/or coverage of the AUC. CareSelect Imaging incorporates AUC from all medical specialty society qPLEs to provide comprehensive indication coverage to cover the PCAs and beyond.

How do I ensure that claims are payable under PAMA?

The process to submit claims and measure outliers using this data has not yet been specified. The PCA have only been defined with enough specificity this round to inform mechanism producers and AUC publishers. We can expect more information in the next two rule making cycles.

We do know that both the Decision Support Number (DSN) generated by the CDSM, together with the indication, will be the cornerstone to the claims process. Limiting an implementation, specifically indication and AUC coverage at the front end, will risk proper claim formation.

I get lots of orders from the fax machine. How can I ensure these orders translate into payable claims?

The regulation is very clear about the requirement for the ordering provider to access the AUC and generate the evidence. It does not provide, nor endorse scenarios, for anyone besides the Ordering Professional to access to the qCDSM as a proxy.

NDSC has integrated its mechanism into all acute/ambulatory EMR applications. Our web portal, where providers can interact with the AUC, is also freely and widely available. This allows ordering providers to generate the Decision Support Number and Indication at the access point and ensure compliance.

Any other final thoughts?

It is tempting to interpret the final rule as a “specification”. In reality, it is a regulation designed to inform market implementations so there is flexibility to the extent that a workable system can be created. This said, I don’t see how a system can generate a payable claim, ensure providers are not outliers and have a system that is routine and accepted by ordering providers without implementing comprehensive indication coverage.

Read NDSC’s Full PAMA Breakdown