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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

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

 

A PAMA Consultation

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When we start the conversation about imaging decision support one topic always jumps to the forefront – “PAMA”. The sections of 2017 MPFS proposed rule that relate to the implementation of decision support for compliance with the Protecting Access to Medicare Act of 2014 (PAMA) have a lot of nuances. From what we’ve heard out in the market, interpreting these nuances can be a daunting and confusing task.

pama-blog-imageWhat We Know

When diving in to the CMS proposed rule, four basics for PAMA compliant CDS implementation appear to be clear:

  • The proposed rule mandates that a compliant decision support solution must start reporting by January 1st, 2018.
  • Every imaging order placed must consult (e.g. ask a question of) a Clinical Decision Support Mechanism (CDSM) that leverages Appropriate Use Criteria (AUC) published by one or more qualified Provider Led Entities (qPLE).
  • At a minimum a CMS qualified CDSM must return one of at least three answers:
    • Complies with an Appropriate Use Criteria (AUC)
    • Does Not comply with an AUC
    • No Applicable AUC Available
  • Priority Clinical Areas (PCA) will be used by CMS to “identify outlier ordering professionals”. PCA are a list of broadly defined clinical conditions, E.g.: abdominal pain, that create a measurement baseline by defining “required” AUC coverage for a CDSM. Today, PCA cover clinical scenarios indicated for approximately 40% of all high cost exam orders. PCA will expand to cover more clinical scenarios each year.

What We Don’t

The access and claims reporting requirements remain undefined. These processes are part of the future rule-making process and will not be addressed in the final rule due out this November. Two main requirements remain unclear:

  • The reporting requirements, including how to submit claims in order to ensure compliance is “measured”, at least minimally linked to the PCA, and ideally ensure that the program “works”.
  • The algorithm by which providers will be defined as “outliers” and the additional authorization hurdles that they will be subject to.

A Real World PAMA consultation

In the real world, a PAMA consultation is an order placed in the EMR for Medicare Part B advanced imaging.

During the ordering process the user asks the CDSM a “question” via a structured, coded indication or reason for exam.

To comply with PAMA, the CDSM must reference AUC and return an answer of ‘Complies’, ‘Does Not Comply’ or ‘No AUC Apply’. It is important to note that the CDSM must respond for every exam ordered.

Priority Clinical Areas

PCAs do one thing – define areas for provider measurement. It can be tempting to think that your organization might get away with a solution that only covers the PCAs with a supposedly simpler CDSM interaction. This however is not the case.

By limiting CDSM AUC coverage to only select clinical areas, PCAs only constrain the number of useful responses a CDSM can provide. The answer of ‘No AUC Apply’ does not ensure the correct order is being placed, merely that the system “Does Not Know”. Additionally, as PCAs define outlier measurement, the ordering user needs to know if an AUC applies (is within a PCA) for the indication they are placing the order for to avoid becoming an outlier.

When other CDSM developers talk about AUC, it is critical to understand that there is a lot of catch up that non-medical society qPLEs have to do to “re-invent the wheel.” This can lead to significant gaps in coverage and a high percentage of ‘No AUC Apply’ answers. CareSelect Imaging leverages AUC from all qPLE medical societies. These societies have invested tens of thousands of hours to develop evidence-based AUC that help doctors use the right imaging test to answer their clinical question.

As these clinical questions (a specific description of the patient condition) are the best way to get an answer through imaging (the most appropriate imaging test), you can imagine that providers seek both specificity and coverage. PCAs really don’t limit the questions in any way especially as the claims process is as yet unknown. A complete payable claim requires both evidence of CDSM consultation and to be coded with enough clinical specificity to ensure that outlier status is avoided. When AUC coverage is limited only to the scope defined by the PCAs this becomes impossible.

Beyond Compliance

A specific clinical question transcends compliance. A clear, concise indication informs the ordering, protocoling and interpretation of imaging and results in less re-work for furnishing services.1 When a CDSM, like CareSelect Imaging, allows you to properly frame questions and gives useful answers, interaction becomes routine and helpful vs. punitive and “fatiguing”. This enables the CDSM to provide useful guidance to the user for every imaging order.

A shorter list of “questions”, organized around the PCA, would force the provider to ask questions that will ensure the “right answer”. This effectively creates an environment where providers game the system, and the furnishing site is forced to verify the question truly matches to the answer to ensure there is a valid, payable claim.

Next Steps

Based on our analysis of the published claims data in the proposed rule, the 8 clinical areas in the proposed rule still cover well over 450 clinical indications, ranging from diagnostic to cancer and cardiac imaging.

The known claims data, released by CMS2, indicates that far more than 8 questions will be necessary, with a further expansion in next year’s rule. If you limit the questions, you will end up with an incomplete system and the answers and evidence will not be clear enough to generate a payable claim (aka comply).

So then, does the rulemaking cycle even matter when deciding how to implement? Whether it is 8 or 80 priority clinical areas, we already know what we need to know about implementation of the provider side and how to prepare for compliance on the claims side: comprehensive coverage.

Every single day another health system adopts our imaging solutions or brings our solutions online within their EMR. Over the last 12 months, we have provided over 20 million AUC consultations at over 1000 acute care facilities with over 100,000 physicians accessing our solution. We know how to do this.

Consult with your EMR vendor about implementing PAMA compliant imaging decision support with ACR Select or our CareSelect Imaging solution. In this case, the answer is clear.

  1. Rockford Health System, “HIMMS Analytics Stage 7 Case Study,” http://www.himssanalytics.org/system/files_force/Rockford%20Health.pdf?download=1
  1. “Data Analysis – Centers for Medicare and Medicaid Services,” https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/data.html