There has been some confusion about the looming deadlines for complying with new Federal regulations concerning the use of Qualified Clinical Decision Support Mechanisms (qCDSMs). Mandatary use of qCDSMs will be the law as of January 1, 2020, about six months from now. And, while payment denials stemming from lack of compliance will not start until a year later, on January 1, 2021, the 2020 deadline is arguably the only one you need to worry about.
Indeed, if you aren’t using an qCDSM by the first of the year in 2020, you are guaranteed to face many payment denials and reviews. Let’s take a moment to review what’s happening, what it means to your radiology business and how you can prepare for the new ways of doing things.
First, Some Background
CDSM stands for “Clinical Decision Support Mechanism.” This refers to an interactive software tool doctors use to comply with rules known as “appropriate use criteria” or AUC information. The doctor relies on the assistance of the CDSM to make the most appropriate treatment decision for a given clinical condition. Medical order management systems like iOrder offer CDSM functionality, as do some electronic health record (EHR) software packages.
PAMA: The Law and the Introduction of the qCDSM
The Federal Government’s Protecting Access to Medicare Act (PAMA) of 2014 contains rules meant to increase the proportion of appropriate advanced diagnostic imaging services being provided to Medicare patients. Services included under PAMA include CT scans, PET cans, MRIs and nuclear medicine.
Under PAMA, doctors who order advanced diagnostic imaging services for Medicare patients must have their support staffs use a qualified CDSM or qCDSM. A qCDSM is a decision support mechanism approved by designated entities authorized by the Federal government. It provides a determination as to whether a service order adheres to AUC. There are several approved qCDSMs now in operation.
Is this really mandatory? Yes… You must take this seriously or face costly consequences. The PAMA/qCDSM regulations call for penalties for practitioners who exhibit ordering patterns that are statistical outliers. An outlier might mean an MRI order that does not meet AUC. The doctors making such orders will become subject to prior authorization. There will also be non-reimbursement penalties for services that do not meet AUC, starting on January 1, 2021
Getting Ready to Comply with PAMA
The government has provided for an incremental rollout of the qCDSM mandate. Right now, we are in a trial phase. By January 1, 2020, use of qCDSMs will be completely mandatory for medical practices that treat Medicare recipients. How can you get ready to comply with PAMA? Based on our experience working with many medical practices on this process, we have the following recommendations:
- Get a qCDSM-compliant order management technology in place before the deadline. This is non-negotiable. Whatever solution you choose, it needs to enable your clinical staff to place orders for imaging services through a qCDSM interface.
- Train your people on the proper use of the qCDSM. It’s not enough to get the tool. People need to know how to use it effectively. Otherwise, it either won’t get used or it will get used but still result in payment denials.
- Train your people on the overall PAMA and qCDSM regulatory environment. The PAMA compliance process will go better if your people see the bigger picture. They need to understand why the new tools are mandatory—that it’s the law, but also a critical element of getting paid.
- Provide underlying technical support. If automated online order management is new for your practice, it’s worth making an investment in technical capabilities to support the solution. This might mean getting tablet computers, improving the Wi-Fi network and so forth. It’s a one-time outlay, but it will pay for itself through a reduction in payment denials and reviews.
iOrder and Integrated Decision Support
We can help you comply with the qCDSM mandate by the time it lands in six months. iOrder provides the capabilities you need to comply with this mandate through a complete order management system that integrates with a qCDSM. To learn more about iOrder’s qCDSM capabilities, visit http://iprohealthcare.com/
