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.
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.
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