The Centers for Medicare & Medicaid Services has pushed back the financial penalty phase of its appropriate use criteria (AUC) requirement for advanced diagnostic imaging until Jan. 1, 2022. The program launched Jan. 1, 2020, with Medicare requiring proof that clinicians who order advanced imaging for their outpatients have consulted an approved appropriate use knowledge base. This year was supposed to be a testing year, with penalties kicking in starting in January 2021.
A notification on the CMS website says: “Now the program is set to be fully implemented on Jan. 1, 2022, which means AUC consultations with qualified CDSMs [clinical decision support mechanisms] are required to occur along with reporting of consultation information on the furnishing professional and furnishing facility claim for the advanced diagnostic imaging service. Claims that fail to append this information will not be paid. Prior to this date the program will operate in an Education and Operations Testing Period starting January 1, 2020, during which claims will not be denied for failing to include proper AUC consultation information.
Describing it as another flavor of pre-authorization, imaging informatics executives are working to make compliance easy for ordering providers who are not on the same electronic health record system.
During a webinar put on by the Society for Imaging Informatics in Medicine last December, Keith Hentel, M.D., executive vice chairman of the Department of Radiology at the New York-Presbyterian Hospital/Weill Cornell Medical Center, described his organization’s approach to getting ready for Protecting Access to Medicare Act (PAMA).
Weill Cornell has 10 years of experience of integrating clinical decision support about appropriate imaging into its Epic enterprise EHR. It is a qualified provider-led entity under the PAMA program, which means it is allowed to create its own appropriate use criteria or endorse the criteria of others. Hentel said the foundation of its approach to clinical decision support is the integration with Epic. Its approach is to apply clinical decision support to all patients, whether they are on Medicare or not.
The challenge with extending appropriate use criteria decision support to community providers is the diversity of systems involved. “Not everyone is within our electronic health record and not everyone is going to be submitting orders to us electronically,” Hentel said. “We still deal with a lot of paper and fax orders.”
“We have been working really hard to use appropriate use criteria to improve the value of care delivery and to eliminate exams that are not necessarily needed,” Hentel said.
He said imaging executives have to ask themselves how they can make sure the decision support interaction takes place, the required codes are added to the Medicare claim, and that they have a copy of that decision support number if they get audited. It sounds like a lot of work, but Henzel describes it as just another flavor of pre-authorization. “We are used to making sure that we have a specific code associated with an imaging exam before we do it or otherwise we are not going to get paid. Commercial insurers have been doing this for years. In many ways, the appropriate use criteria program is better, because there is a lot more transparency and more rigor around how the rules are created that suggest and deny imaging. But when you distill it down, it really is pre-authorization all over again.”
So what is Weill Cornell’s overall strategy for dealing with orders that are coming from outside its EHR? “The No. 1 thing is I want to make our clinical decision support solution easy to use for ordering providers that are going to be sending to us,” Henzel said. He emphasized that if his organization makes it cumbersome and somebody else makes something that is easy to use, referring physicians are not going to send their patients to Weill Cornell. “So it has to be easy to use and offer value to the patient and provider.”
