Satisfying The CMS Mandate For Clinical Decision Support In Advanced Imaging Orders

By Juliana Hart, BSN, MPH and VP Market Development at medCPU and Nancy Zimmerman, RN, BSN, Senior VP of Strategic Accounts at medCPU

On Nov. 2, 2016, The Centers for Medicare & Medicaid Services (CMS) released the Medicare Physician Fee Schedule (MPFS) final rule for 2017. The final rule includes significant clarification regarding the 2014 Protecting Access to Medicare Act (PAMA) mandate to use clinical decision support (CDS) when ordering advanced imaging for Medicare beneficiaries, which takes effect Jan. 1, 2018.

The impact by place of service includes all Part B claims for facility and professional charges under the following regulations: Physician Fee Schedule (PFS), the Hospital Outpatient Prospective Payment System (HOPPS), and the Ambulatory Surgical Center (ASC) payment system.

With the deadline looming, providers will need to begin preparing soon. The following provides an overview of key considerations from the MPFS final rule, along with suggestions for ensuring an especially satisfying CDS acquisition.

Which Solutions Qualify: Certified CDS Mechanisms (CDSM)

PAMA requires CDS systems used to support advanced imaging orders incorporate appropriate use criteria (AUC) defined by provider-led entities. Ahead of the MPFS final rule, CMS approved 11 provider-led entities for the creation and modification of AUC. This list will grow as CMS accepts applications from additional provider-led entities each Jan. 1.

The MPFS 2017 final rule clarified the qualifying requirements for CDS mechanisms (CDSMs) that reference AUC in advanced imaging orders. To qualify as CDSM, vendor solutions must:

• reference more than one approved AUC source
• assign a unique identifier to each advanced imaging order
• give providers aggregate data annually to identify trends in utilization and appropriateness

Vendors will begin applying to qualify as CDSM in 2017, and CMS will publish its initial approved CDSM list by mid-2017. Provider organizations can then begin vendor selection. For 2017, CMS will provide two levels of CDSM certification:

• full qualification will signify the CDSM meets all criteria as of the Mar. 1, 2017, application deadline
• preliminary qualification indicates the CDS vendor has met most requirements by Mar. 1 and has submitted a schedule for satisfying the remaining requirements by the Jan. 1, 2018, provider deadline

While there is some advantage in selecting a CDSM with full qualification, these criteria are straightforward — don’t dismiss a preferred vendor with preliminary qualifications and a solid schedule for becoming fully qualified.

The Radiology Department’s Key Role

Once the mandate takes effect, advanced imaging claims must include three items to receive full reimbursement:

• which qualified CDSM was consulted by the ordering professional for the service
• whether the service, based on the CDSM consultation, adheres to specified applicable AUC, does not adhere to specified applicable AUC or whether no criteria in the CDSM were applicable to the patient’s clinical scenario
• the national provider identifier (NPI) of the ordering professional

Assuring all relevant information is used to identify the patient’s clinical situation is critical to applying the rules. A CDS capable of reading and processing unstructured data from all sources ensures a complete picture and appropriate application of the criteria.

Note that, while CMS is mandating the use of CDSM by physicians who order imaging, responsibility for reporting actual CDSM involvement lies with the imaging provider. As claims rejected for lack of CDSM evidence will negatively impact radiology department reimbursement, provider organizations should involve imaging leadership in preparing for this initiative. Radiology departments can take the lead in educating all ordering providers regarding the regulations, the clinical categories and, in the future, the criteria used.

How CMS Will Identify Outlier Ordering Professionals

Although the mandate applies to all advanced imaging orders, CMS will identify outlier ordering professionals by examining priority clinical areas that the selected CDSM should cover. While CMS may expand its list in the coming years, the initial eight priority areas include:

• coronary artery disease (suspected or diagnosed)
• suspected pulmonary embolism
• headache (traumatic or non-traumatic)
• hip pain
• low back pain
• shoulder pain (to include suspected rotator cuff injury)
• cancer of the lung (primary or metastatic, suspected or diagnosed)
• cervical or neck pain

Provider organizations using CDSM that does not cover all eight priority areas risk being identified as outlier ordering professionals, and will subsequently require preauthorization for advanced imaging orders for Medicare members.

The Importance Of Aligning With Workflows

The MPFS final rule notes the significant feedback CMS received during the commenting period regarding the need for AUC, and thus CDSM, to be integrated as much as possible into clinical workflows. This consideration cannot be overstated, and should be weighted heavily in CDSM selection. Issuing imaging-related prompts within workflows requires a good deal of intelligence.

While there is an exemption when services are provided to individuals with emergency medical conditions (as defined in section 1867(e)(1) of the Act), physicians frequently work under pressure based on initial assessment and chief complaint, and document diagnoses after the situation is under control. To avoid “alarm fatigue,” the CDSM should be intelligently integrated into workflow, identify which screens physicians are working in and issue “just in time” alerts related to imaging orders. This is just one of many considerations an intelligent CDS can give to clinicians who must realize value from it.

Final Consideration: CDS Can Do Much More Than Satisfy PAMA
Intelligent CDS systems can deliver much more value than simply functioning as CDSM for advanced imaging orders. From alerting clinicians to the early onset of sepsis to promoting adherence to published clinical guidelines, CDS systems have become adept at delivering accurate prompts, based on a full understanding of the patient’s clinical condition, within workflows for maximum value. In evaluating CDS options to satisfy PAMA, one of the most important questions to ask your vendor is: what else can it do for me?