Ryan K. Lee, MD, MBA
It has been quite some time since clinical decision support for radiology was mandated by CMS. In 2014, the Protecting Access of Medicare Act (PAMA) required the use of appropriate use criteria for advanced diagnostic imaging studies. To place into context just how long ago this mandate was put into place, the Medicare Access and CHIP Reauthorization Act (MACRA) which gave us the Quality Payment Program and thus the Merit-based Incentive Payment System (MIPS) was announced in 2015, a year after PAMA.
During this time, increasing details of the requirements of using clinical decision support have been added by CMS. And each year the implementation of this mandate has been delayed. Spoiler alert for this year: the requirement in the use of appropriate use criteria for advanced imaging studies which was set to begin on January 1, 2022 is likely to be delayed at least another year, as outlined in the Medicare Physician Fee Schedule (PFS) Proposed Rule for CY 2022. Recall that the penalty for noncompliance of using CDS is nonpayment of the performed studies. More specifically, these penalties associated with eligible studies obtained without evidence of use of a clinical decision support mechanism (CDSM) is proposed to be delayed to January 1, 2023, or the January 1 after the declared end of the COVID- 19 public health emergency, whichever is later. CMS admitted in the current PFS proposal that it does not have the infrastructure in place to process these CDS claims, and this is one of the reasons that the implementation of CDS has again been delayed.
As a review, there are three required elements of PAMA once it is implemented:
1. The CDSM used by the ordering professional
2. Whether the study ordered adheres to or does not adhere to the AUC, or if it does not apply
3. The NPI of the ordering professional
Requirement #1 is simply identifying the software used for clinical decision support. Each qualified CDSM is designated a unique G-code which is to be included on all claims. Requirement #2 represents information regarding the appropriateness of the study based on the AUC (modifier ME- adheres, modifier MF- does not adhere). Alternatively, if AUC was not consulted, information as to why it was not consulted is to be included using the following modifiers previously identified by CMS:
- MA: no CDS consult required due to service rendered for patient with or suspected emergency medical condition
- MB: no CDS consult required due to significant hardship exception of insufficient internet access
- MC: no CDS consult required due to significant hardship exception of HER or CDSM technical issues
- MD: no CDS consult required due to significant hardship exception of extreme and uncontrollable circumstances
- MG: order for this service does not have AUC in the CDSM used
In addition, previous communication from CMS clarified that an ordering professional could designate an individual to utilize the CDSM on their behalf, with the ordering professional being ultimately responsible.
In the current PFS proposal, CMS is proposing clarification on so-called modified orders. In some cases, once a patient arrives for their imaging study it may be the case that the radiologist has need to perform a different study than what was originally ordered. Under routine circumstances, this new study can only be performed upon receipt of a new order from the ordering professional (and with CDS information for the new order) since a radiologist cannot consult CDS. However, CMS is proposing that in emergent situations in which delay of care could have an adverse effect on patient care, the radiologist can proceed without a new order from the ordering provider and furthermore not have to go through the AUC consultation.
The granular detail included in this year’s proposed physician fee schedule is an indication that despite the probable delay, CMS is serious in implementing the PAMA mandate. As such, it behooves us to use this additional time allotted by CMS to ensure the CDS mechanism in our practices are functional prior to the implementation date to ensure that our studies are reimbursed.
Many of you already have your CDSM up and running in your EHR and that is great- you only have to ensure you pass through the three elements required by CMS on your claims and you are all set. Don’t forget however those ordering professionals that are outside of your network, i.e., those ordering professionals that do not use your EHR. These ordering professionals will need a method of getting you those three required elements to you in an alternate manner and this workflow is likely more complicated. CMS realizes this additional complication and though unstated it is likely another reason for the delay in implementation.
Although not perfect, CDS has the potential to improve patient care by promoting appropriate use of imaging studies. While it is in our interests to have CDSM working properly in our systems from a reimbursement standpoint, it is most importantly in the best interests of our patients that we utilize this technology to best advantage.