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New CMS Appropriate Use Criteria mandate for CDSM will impact Medicare reimbursement


Don’t let your Medicare Part B reimbursement for advanced imaging be impacted by the CMS Mandate taking effect on January 1, 2022!

We’re partway through the educational period before the CMS Mandate governing the new Clinical Decision Support Mechanism (CDSM) and the Appropriate Use Criteria (AUC) Program takes effect on January 1, 2022. Tasked with improving diagnostic accuracy for physicians when ordering advanced imaging, this new CMS Mandate is part of the “Protecting Access to Medicare Act” (PAMA) passed by Congress in 2014.

Enacted to reduce needless imaging procedures and support referring providers when ordering diagnostic testing, the new mandate requires furnishing providers to submit the results of a CDSM consultation when submitting Medicare Part B claims for advanced imaging services to receive reimbursement. This means that substantial revenue could be at risk for radiology, cardiology, and orthopedic practices, as well as free-standing imaging centers and outpatient hospital facilities that perform advanced imaging for Medicare Part B patients.

It’s important to note that inpatient services (billing for Medicare Part A), emergency patients, and ordering physicians with significant hardship, such as proximity to internet services, have been excluded from the mandate.

CDSM Requires Unique Synergistic Cooperation

The new criteria impact reimbursement for advanced testing includes MRI, CT, nuclear medicine, and PET. Referring or ordering providers are required to consult a qualified CDSM (qCDSM) that provides imaging decision guidance based on appropriate use criteria (AUC) and generates a “Certificate of Consult”. Similar to prior authorizations, it is furnishing providers who will need to validate and provide details of the consult while filing claims for advanced imaging with CMS and whose reimbursement is at risk without receipt of the information

As part of the design/implementation phase, CMS worked with a number of approved vendors to develop advanced automation that integrates with existing EHR/EMR and billing systems. This software allows the ordering provider to consult AUC so that the furnishing provider can submit the required certificate and ensure payment from CMS.

Are Providers Ready?

As the initiation phase has gotten underway, one issue has become readily apparent—the new requirement has been lost on ordering providers and their offices. This is why CMS gave such a lengthy educational period for implementation (previously extended from January 1, 2021).

According to a survey by a large imaging center of its ordering providers, less than 10% of the providers knew of or understood the CMS mandates around CDSM. This poses a challenge for imaging providers who may be asked to proceed with Medicare imaging requests without a CDSM consult.

If the ordering provider has not consulted the AUC, then the furnishing provider is required to go back to the ordering provider, request a CDSM consult, and then move forward with the patient’s care. Needless to say, this creates an administrative burden on the furnishing provider and can potentially impact patient experience.

What’s the Right Digital Answer?

Ideally, the ordering provider would consult a qCDSM for necessary details prior to sending any order to an imaging provider. But imaging providers should prepare for the possibility of no consultation and a subsequent need to follow up with the ordering physician before the appointment.

A true furnishing-provider-centric CDSM solution should identify the requirement for a CDSM consult and pinpoint missing consults in incoming orders. For these missing consults, it should make it easy for the furnishing provider to inform the ordering provider of the missing consult and also provide them a qCDSM solution to complete a consult. This will ease the burden on the furnishing provider, ensure that the consult is completed, and guarantee reimbursement.

Additionally, any electronic solution should include coverage for all priority areas of clinical practice. These areas were identified by CMS as “coronary artery disease (suspected or diagnosed), suspected pulmonary embolism, headache, hip pain, low back pain, shoulder pain (to include suspected rotator cuff injury), cancer of the lung (primary or metastatic, suspected or diagnosed)”.

CDSM Coding is Key to Reimbursement

Working with the American Medical Association (AMA), the keeper of CPT Procedure Code protocol, CMS announced HCPCS Modifiers and G Codes that must be used to define CDSM and to modify CPT procedure codes. The HCPCS Modifiers relay the results of the consult and provide a unique consult identifier, while the G Codes define which CMS approved vendor was utilized.

To Sum Up

Since the initiation of the educational period on January 1, 2020, the CMS Mandate is being tested and refined as practices revamp their workflow to include AUC. One concern being voiced industry-wide is that many practices don’t fully understand their obligations or how it will impact their Medicare reimbursement in 2022 and beyond.

As furnishing providers, now is the time to reach out to your ordering provider base and help them through educational opportunities and process support. Also, solutions that identify missing consults and can inform and guide the ordering providers to get a consult easily will further reduce denials. Adding one more requirement on an already overburdened staff may be better received in a collaborative environment.

Appropriate Use Criteria Program. CMS.gov – Centers for Medicare & Medicaid Services. https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/appropriate-use-criteria-program. Accessed on 4/2/2019.
Clinical Decision Support Mechanisms – Appropriate Use Criteria Program. CMS.gov – Centers for Medicare & Medicaid Services. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/CDSM. Accessed on 4/2/2019.
Priority Clinical Areas – Appropriate Use Criteria Program. CMS.gov – Centers for Medicare & Medicaid Services. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/PCA. Accessed on 2/12/21.

About the Author
Navaneeth Nair is Vice President of Products at Infinx Healthcare which provides leading-edge AI-assisted end-to-end solutions across the payment lifecycle, including patient access, prior authorization, and revenue optimization. Navaneeth has over 20 years of experience in healthcare, where he has specialized in leading large-scale technology product and solutions developments.
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