Prepare now for Medicare's AUC/CDS rules for imaging orders

Jun 22, 2021

2019 11 13 00 46 2926 Business Deal Corporate 400

On January 1, 2022, radiology practices and hospitals that perform certain imaging services for Medicare patients will be denied payment unless they submit documentation that the ordering physician has consulted a clinical decision-support (CDS) system.

This regulation was included a few years ago in Medicare rulemaking, but its effective date has been delayed several times. As of now, there is no reason to believe it will be postponed further, so practices that have not yet taken steps to install and implement a system have a narrow window of opportunity to get ready.

A review of the requirements

The regulation requires ordering physicians to consult appropriate use criteria (AUC) using a qualified clinical decision-support mechanism (qCDSM) that is approved by the U.S. Centers for Medicare and Medicaid Services (CMS) prior to ordering CT, MR, nuclear medicine, and PET exams for outpatients covered by Medicare Part B. It applies to outpatient imaging services performed in the hospital outpatient department, hospital emergency department, radiology office or imaging center, ambulatory surgery center, or in an independent diagnostic testing facility. The site where the imaging is performed, not the ordering site, determines the need to use CDS.

There are a few exceptions to the requirement that an AUC consultation take place for the claim to be paid:

Inpatient services covered under Medicare Part A are not subject to the regulation.
Services performed at a critical access hospital (CAH) are not subject to the regulation.
No AUC consultation is required when certain hardship circumstances exist for the ordering professional. These include the following:

Insufficient internet access
Electronic health record (EHR) or qCDSM vendor issues. For example, issues might include technical problems, installation or upgrades that temporarily impede access to CDSMs, a vendor ceasing operation, or a CDSM losing its qualification.
Extreme or uncontrollable circumstances (including natural or manmade disasters)

Services ordered for an individual with an emergency medical condition¹ do not require a consultation, regardless of the location where those services are performed. The ordering physician's determination of an emergency condition will govern. However, while some are relying heavily on this exception, CMS has indicated that the majority of emergency department cases will not be exempt.

In addition to these exceptions, no AUC consultation and reporting will be required by Medicare Advantage plans (Part C) or when Medicare is a secondary payer unless the primary payer has such a requirement. In cases where the radiologist adjusts the exam, such as to add contrast to a noncontrast order, it is not necessary for him or her to consult a CDSM; the original consultation by the ordering physician is sufficient.

While the ordering physician does not have to follow the AUC recommendation of the CDSM, he or she must use the CDSM and provide the imaging facility with the appropriate information to include on their Medicare claim. Our January 2020 article goes into more detail about performing and reporting the AUC consultation.

Practices should be testing now

Since these regulations have been pending for so long you would suppose that most hospitals and radiology groups are prepared by now, but that unfortunately may not be the case. The Medicare claims system is in place to process the AUC consultation coding on a test basis. Information will be returned to the practice about the adequacy of its submission, but payment will not be denied for missing information. Commercial payers should be contacted about their CDS requirements.

A practice with multiple imaging sites will have to evaluate its readiness at each one. Obviously, preparing at a physician-owned private office or imaging center will be an entirely different process than working with a hospital. Hopefully the hospital realizes that its reimbursement is at risk as much as the radiologist's is, so the effort to implement CDS should be collaborative.

The radiology group might offer to spearhead the project, with compensation from the hospital, if the institution cannot move ahead quickly enough. Quantifying the potential financial impact of payment denials for the affected imaging services might help get things moving if there is resistance.

Regardless of the site of service, the referring physician community has to be educated about the need to consult the CDSM. The consultation must be done by the ordering physician or their staff, not by the imaging facility. The hospital and practice marketing teams should be included early on to get the word out to the community, including not only those physicians within the same health system but also those outside physicians who are important referrers to the practice.

The education process should include the steps required to perform the consultation as well as the relevance of the process to improving patient care. If you are not using a CDSM that is part of your own practice's ordering system, be ready to help the referring office staff members set up their account with one of the free CDSMs available.

Long-term implications for ordering physicians

CMS will refer to AUC and CDS data to identify the top 5% of providers who most frequently order inappropriate imaging. They will then require prior authorization for any advanced imaging services ordered by those outlier providers.

The following priority clinical areas have been identified by CMS:

Coronary artery disease (suspected or diagnosed)
Suspected pulmonary embolism
Headache (traumatic and nontraumatic)
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

Changing criteria

The American College of Radiology (ACR) periodically updates its appropriateness criteria. The most recent revision issued in April 2021 contained 13 new topics and revised five others.

Resources

CMS has published several documents that can be useful, and the ACR and the Medical Group Management Association (MGMA) both have good information available:

Conclusion

Time is running out for radiology practices to get ready. Evaluate each site of service to determine which system will be used, and then develop a timetable to thoroughly educate the referring physician community. Working in conjunction with the hospital can be beneficial to get the word out.

Be sure to verify that your billing system, whether in-house or outsourced, is ready to capture and transmit the required coding to CMS and test it with a few submissions to be sure everything is ready to go. We will keep you apprised of any changes as the deadline approaches.

Sandy Coffta is the vice president of client services at Healthcare Administrative Partners.

The comments and observations expressed are those of the author and do not necessarily reflect the opinions of AuntMinnie.com.

¹ An "emergency medical condition" is defined under the Emergency Medical Treatment And Labor Act (EMTALA) as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. In addition, with respect to a pregnant woman who is having contractions, an emergency medical condition exists when there is inadequate time to effect a safe transfer to another hospital before delivery, or that transfer may pose a threat to the health or safety of the woman or the unborn child.