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Use of Clinical Decision Support (CDS) software by the medical community has long been an expectation of the Centers for Medicare and Medicaid Services. CDS software provides vital tools to assist physicians and their teams in making informative, swift decisions. From diagnostic support to patient data reports, CDS can assist physicians in all specialties in determining appropriate use criteria (AUC). For commercial insurers, the requirement for pre-authorization for high-end tests and procedures is not new. For Medicare, however, the proposed Federal rulings will result in a change in requirements for the use of CDS systems for authorization of CT, nuclear medicine, MRI, and PET scans.

According to Federal Register Proposed Rule CMS-1676-P, beginning January 1, 2020, advanced outpatient imaging tests for Medicare patients must first consult an approved CDS system. If the system is not consulted, the imaging test will not be approved for billing. This new rule aims to reduce regulatory burdens and assist physicians in selecting the imaging test that would best improve health outcomes for patients, based on the unique needs of those patients. It also looks to aid furnishing providers, such as radiologists, by providing consultation information and ensuring that patients are getting appropriate imaging.

Edwin Swager, CEO of Radiologic Associates of Fredericksburg, adds that the new rule will not initially prevent a provider from advanced imaging procedures even if the applicability or ranking of the test is deemed low, but that beginning in 2021 CMS will evaluate an ordering provider’s appropriateness compared to their peer group and will not pay for advanced imaging procedures without use of CDS. “The ordering provider, in theory, would order high-end imaging like they always do, but would utilize CDS software, ideally as an application within their existing Electronic Health Record (“EHR”) system, to enter the imaging procedure and clinical indications in order to obtain a CDS reference number and to know the degree of appropriateness of the study based on the clinical appropriateness rating. Eventually, in time, providers ordering studies scoring with low relevance would be required to obtain preauthorization from Medicare.”

The release was originally slated for the beginning of 2018, then extended to 2019, and is now postponed to January 1, 2020. “Ever since the proposed rule was introduced several years ago, Radiologic Associates of Fredericksburg has been preparing for the CDS change. With the date of implementation now January 1, 2020, this will give vendors and providers another 12 months to have the appropriate software, as well as implement the new codes and modifiers from Medicare,” Swager explained.

According to Mr. Swager, the first year of the ruling will be mostly educational, allowing both the physicians and the CMS to implement the new software and see how it truly works. “The first year is an educational and testing year, which will give everyone more time to meet the complexities and changes that are coming.”

Radiologic Associates of Fredericksburg and Mary Washington Healthcare have been working to ensure that the transition is as seamless as possible for both physicians and patients. By collaborating with National Decision Support (NDS), the developer of one CMS’s qualified clinical decision support mechanisms, their goal is to make certain every provider’s system is up to date and ready for the change. “If an ordering provider does not have the software, then we’ll look to provide some web-based tool for them,” Swager stated.

A cross-functional team has been created, comprised of leaders from RAF and the key leaders from Mary Washington Health, including the Chief Information Officer and Chief Medical Information Officer as well as various other departments to ensure providers are well informed and well supported.

“We have worked to establish a plan to establish multiple pathways for ongoing communication and educational support for ordering providers. Throughout the year, we will be conducting a provider inventory to determine who is currently ordering through EPIC. If a provider is not using EPIC, we will then determine if the EHR vendor of the practice or the physician is already CDS prepared or if the provider or practice is looking to order through EPIC in the future. We will also be working with National Decision Support, one of the companies that licenses the software and that licenses with EPIC,” Mr. Swager explained.

Just as when conversion to ICD-10 was implemented, education and information will be provided through several resources, including RAF and MIF websites, which will have the information and support that is needed so that the transition to CDS might become part of the providers’ standard workflow. As providers go into their EHR or EPIC imaging portal, it will automatically launch the CDS software when imaging orders are being created.

For ordering providers who are using their own EHR and not ordering through EPIC, an estimated 20% of EHR vendors may not be prepared. Although the cross-functional work team is working to facilitate the transition to CDS, Mr. Swager advises ordering provider to work with their EHR vendor now to be better prepared. For patients in the region who may be concerned that this ruling could affect their medical imaging tests, they are encouraged to have the peace of mind that Radiologic Associates of Fredericksburg has ensured appropriate imaging tests for years. “As with all payor types, our group has historically reviewed Medicare claims and Medicare procedures to make sure that they’re the most appropriate studies,” said Mr. Swager. “We have already been doing that part of the process.”

Timeline for CDS Mandate

● 2019: Preparations continue during voluntary reporting period for early AUC adopters.
● 2020: Educational and operational testing period. Penalties for incorrect reporting will not be administered to rendering physicians.
● 2021: Broad scale analysis to be conducted. Payment will be withheld and outlier calculations and compliance reporting will begin.

Becoming PAMA AUC Ready

● Become familiar with communications by RAF, MIF, and the Mary Washington Healthcare systems.
● Check with EHR vendor for current status and expectations for future support.
● Look for information from RAF’s Communication Support Group in the first quarter of 2019.

Providers with questions should call Radiologic Associates of Fredericksburg at (540) 361-1000. Radiologic Associates of Fredericksburg will continue to update providers as the changes are implemented.

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