New Medicare Rule Requires Clinical Decision Support Proof

In 2017, Newsletter, Volume 9 Issue 2 by Addison Clark

According to current Medicare regulations, starting January 1, 2018, providers who order advanced outpatient imaging tests for Medicare patients must first consult with an approved clinical decision support (CDS) system or the studies will not be covered, reported Edwin Swager, CEO of Radiologic Associates of Fredericksburg (RAF).

As many as one-third of medical providers nationally are unaware of the upcoming change, Swager learned at industry conferences.

The new rule applies to advanced medical imaging studies including magnetic resonance imaging (MRI) and computed tomography (CT) diagnostic tests ordered at freestanding imaging centers and hospital imaging centers, he said. Unless the final rule changes, starting in January, a medical provider ordering these tests must first consult with approved clinical decision support software. The software will then generate a unique identifier required for Medicare to cover the study.

While some medical providers’ electronic health record (EHR) vendors are working to have the necessary clinical decision support capabilities, the majority do not have them, added Swager. He initiated a workgroup of RAF, Mary Washington Healthcare, and Medical Imaging of Fredericksburg professionals who began studying the issue in 2016.

The workgroup has been reviewing existing EHR vendor CDS capabilities and possible alternatives for physicians whose systems do not already have the appropriate clinical decision support. The group is also establishing education and tools for local medical providers about the issue.

“We are urging medical providers to make sure their EHR vendors realize that they must have access to a Medicare-approved clinical decision support platform,” Swager noted. “For practices that do not have this capability, the workgroup is evaluating alternative platforms for generating unique identifiers.”

More information, including recommended alternative platforms, will be announced by the local workgroup this summer. Medicare is expected to release its approved list of clinical decision support platforms by June 30, 2017.

The new rule is intended to ensure that ordered tests meet Medicare’s appropriate use criteria. It is part of an increasing emphasis on evidence-based medical practices and improved outcomes, Swager added. Unfortunately, whether a provider agrees or disagrees with Medicare’s approach, unless the final rule changes, providers must work together to best meet the diagnostic needs of patients.

Over time, Medicare is expected to evaluate each provider’s appropriate use compared with that of other physicians. Medicare may require physicians whose measures fall beneath certain norms to obtain preauthorization before ordering advanced outpatient imaging studies for patients, he noted.

Medical providers who would like more information about the new rule can visit the RAF website at decision-support.