Clinical Decision Support

The Protecting Access to Medicare Act of 2014 (PAMA) requires an appropriate use criteria (AUC) consult to be performed via a Centers for Medicare and Medicaid Services (CMS) qualified clinical decision support mechanism (qCDSM) when a healthcare provider orders advanced diagnostic imaging for Medicare patients.

CMS Clinical Decision Support Program Paused — Not Repealed

The AUC-based CDS program is not cancelled or repealed. The 2024 Medicare Physician Fee Schedule final rule simply paused implementation while Congress considers legislative CDS improvements. The American College of Radiology ® (ACR ® ) will continue to work with Congress and CMS to eliminate the real-time claims processing requirement that has resulted in this pause. ACR and CMS urge providers that have already implemented CDS to continue its use during this pause. The resources below can help practices and referring providers prepare to comply with the CMS mandate when it moves forward. For more information, see the PAMA/AUC page and listen to the AUC/CDS webinar on demand.

More Information

Educate Referring Providers With the PAMA-AUC Toolkit

• NEW— CMS Further Delays Imaging Appropriate Use Criteria Program(July 2022)
• NEW — CDS for Appropriate Ordering of Imaging PowerPoint to Present to Radiology Audiences(August 2022)

For radiology professionals to send to referring providers:

• Medicare Learning Network AUC for Advanced Diagnostic Imaging Education Materials
• Advanced Practice Providers AUC resources

Watch On Demand: ACR-RBMA “Medicare AUC Mandate – Countdown to Launch!” Webinar

ACR-RBMA webinar helps get you ready for the Medicare AUC-based clinical decision support requirement. Please note that CMS has since indefinitely delayed the CDS program start date referenced in this webinar.

What You Need to Know

An AUC consult must be documented via a CMS-qualified clinical decision support mechanism (qCDSM). Without a documented consult, rendering providers will not receive Medicare payment for the procedure.

• The law does not mandate ordering providers strictly adhere to the AUC, just consult AUC. There is no “hard stop” to the ordering process.
• Emergency department exams are included in this rule. Inpatient exams are also exempted. The U.S. Department of Health and Human Services (HHS) may make limited exceptions for providers with limited internet connectivity including:
  • Insufficient Internet Access (e.g. rural areas);
  • EHR or CDSM vendor issues (e.g. technical problems, installation or upgrades temporarily impede access to CDSMs, vendors cease operations or CMS de-qualifies a CDSM); or
  • Extreme and Uncontrollable Circumstances (e.g. man-made or natural disasters; area infrastructure issues)

  Resources

  ACR Statements

  • NEW — CMS Further Delays Imaging Appropriate Use Criteria Program(July 2022)
  • CMS Extends Educational and Operations Testing Period for AUC Consultation (August 2020)
  • ACR Detailed Analysis of CY 2019 MPFS Proposed Rule (July 2018)
  • Medicare Releases Final Rule for the Second Year of the Quality Payment Program (Jan. 2018)
  • ACR Summary of Medicare Physician Fee Schedule Final Rule for CY 2018 on Appropriate Use Criteria for Advanced Diagnostic Imaging Services (November 2017)

  CDS Resources

  • AUC Testing Period Claims Processing Requirements Guidance for Providers
  • AUC Change Request Processing Requirements Guidance for MACs
  • CMS Appropriate Use Program: Background, Timeline, Rules
  • Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging Fact Sheet
  • Radiology Support, Communication and Alignment Network (R-SCAN™)
  • AUC Navigator — Navigate to qualified provider led entity sites and Appropriate Use Criteria guidance

  Webinars on Demand

  These webinars provide important information on the Medicare AUC-based CDS requirement. Please note that CMS has now indefinitely delayed the previously-mandated start date for the CDS program referenced in these webinars.

  • Watch: “ACR/RBMA Webinar: "Implementing Clinical Decision Support in Your Practice" (February 2019)
  • Watch: "PAMA AUC Deadline is Firm—Prepare Now for 2020" (December 2018)

  Misconceptions About AUC/CDS Process

  • The current testing period has been extended until further notice. This provides additional time for practices to implement clinical decision support systems (CDSMs). During the period, professionals are encouraged to participate in the program - giving CMS an opportunity to make any needed claims processing adjustments before payments are impacted.

  • Imaging facilities/practices/departments will not have to change their reporting lexicon or approach. Care Select™ Imaging - which is the qCDSM containing the ACR Appropriateness Criteria diagnostic imaging topics - and likely other CDSM vendors as well - can work with imaging providers to incorporate current lexicon into the system workflow.
  • CDS can be done even if referring and rendering providers do not share a common EHR/EMR system. Care Select™ Imaging – which contains the ACR Select® module, which contains the ACR Appropriateness Criteria diagnostic imaging topics - and perhaps other CDSM vendors can serve this function, documenting AUC consultation and providing necessary “identifier” code to include in Medicare imaging claims.
  • Imaging providers will not be competitively disadvantaged by this federal requirement:
    • No rendering provider can receive Medicare payment for an ADIS if the referring provider does not attach a HCPCS/G-codes and modifiers to the referral
    • All radiology providers may refuse Medicare referrals without this documentation, with few exceptions as outlined above
    • Imaging providers cannot perform AUC administrative duties for referrers (as with prior authorization)
    • Ordering providers cannot shift the AUC requirement to radiologists
    • There is no facility “exempt” from PAMA requirements (other than those exceptions outlined above) to which providers can shift this Medicare imaging
    • These factors should quickly result in integration of CDS in referring practices
    • Providers need only consult the AUC that applies to the individual advanced imaging exam to be ordered.
    • In many cases, particularly when the qCDSM does not contain AUC, consultation can be automatic.
    • A qCDSM is required to have reasonable coverage of Priority Clinical Areas (PCA). There is no defined maximum.
    • Having access to comprehensive AUC enables organizations to manage utilization across all services, which can help eliminate the overhead of prior authorization across all payers.
    • As the PCA will expand, comprehensive coverage can help keep practices ahead of future rulemaking.

    Background Materials

    • Imaging 3.0 CDS case studies - Gain insights from other practices and departments that have successfully implemented clinical decision support systems.
    • Clinical Decision Support for Appropriate Imaging – How Did We Get Here?
    • Background and Frequently Asked Questions about Protecting Access to Medicare Act of 2014

    Videos

    • Clinical Decision Support for Appropriate Imaging (set of 4, total 70 minutes)
    • Be PAMA AUC Ready: Act Now
    • Explaining Imaging Appropriateness to Patients without Clinical Decision Support
    • Explaining Imaging Appropriateness to Patients with Clinical Decision Support

    What You Need to Do

    CARE-SETTING SPECIFIC TIPS

    Both technical and professional component claims will ultimately require evidence of consultation to be payable. Practice setting will influence how practices work with referring providers and adapt workflows. Below are care-setting-specific tips gathered through experience to date.

    Hospital Based Practice

    • Ensure that affiliated institutions have integrated qCDSM into their EHR and that the consultation information flows to your revenue cycle applications for professional and technical billing. A good way to measure this is to ensure that the structured indication selected by the ordering provider is available in your interpretation workflow.

    Ambulatory Imaging Practice

    • Educate referrers on availability of no fee access points, including via several ambulatory EMR applications.
    • Ensure workflows and integrations to receive electronic orders include consultation information (if available).
    • Become familiar with AUC consultation process and enable referring providers.
    • In some cases, your practice may only receive a unique consultation identifier generated by the qCDSM. You may need to access or integrate with the qCDSM to retrieve claims data.
    • Ideally the structured indication selected by the ordering provider is available in your interpretation workflow.
    • Sign up for/with the qCDSM to become familiar with the process.

    Private Practice

    • Ensure your professional billings include the necessary consultation data. This will require that your billing company work to include the consultation data into their processes.
    • Ensure that the systems interacted with include the structured indication selected by the ordering provider.
    • Sign up for/with the qCDSM to become familiar with the process.
      

    GENERAL – Across Care Settings

    Make sure your IT, medical and professional staff are aware of the approaching CMS deadline.

    • Explain why you are doing this – legislative requirement and quality improvements – via:
      • grand rounds/staff meetings
      • network emails
      • newsletters

      Ensure that your IT/informatics team is incorporating AUC into your electronic medical record (EMR) and image ordering and fulfillment systems.

      • Meet with various stakeholders:
        • obtain buy-in from administration
        • obtain buy-in from ordering practitioners
        • obtain buy-in from information systems (IS) and information technology (IT)

        Educate relevant staff on how to use the AUC/CDS system you choose – your qCDSM vendor can help.

        • Hold weekly conference calls with vendor, IS/IT and ordering provider leaders.
        • Create instruction video and set up mandatory viewing prior to turning on CDS system.
        • Distribute PDF instruction manual, newsletters.

        ACR resources can help

        • Use CareSelect™ Imaging - ACR Select®, a digital representation of the ACR Appropriateness Criteria ® for diagnostic imaging, is a module contained within CareSelect Imaging™. ACR Select® may be integrated with all major computerized ordering/EHR systems and is freely available to all providers via the ACR Select ® web portal. See other qualified Decision Support Mechanisms approved by CMS.
        • Take part in the CMS-funded Radiology Support, Communication and Alignment Network (R-SCAN™) — administered by the ACR – with your referring providers. Use R-SCAN to get familiar with CDS/AUC, get CME Credit and get ABR maintenance of certification Part 4 Credit.
        • Contact PAMA-AUC@acr.org with questions and for more information.