The best part of providing an ambulatory service is the pure professional pride you have in delivering it, regardless of whether or not you get paid. Actually, we’re just kidding. Of course, you always do your professional best. Getting paid is the whole point. However, getting paid is not quite as easy as it once was, and it never was that simple a matter. Today, reimbursements face more hurdles than ever before. Order management software offers a solution. It potentially speeds up reimbursements and clears the way for services that could face claim reviews and payment denials.

Obstacles to reimbursement in ambulatory service orders

There are several different ways you can provide a service, but not get paid for it. One is to deliver the service incorrectly, requiring you to do it again free of charge. This can result from inadequate or miscommunicated service details.

The main force for payment denials is the newly-tightened set of requirements for service orders, as mandated by the 2014 Protecting Access to Medicare Act (PAMA) law. Now going into full effect, PAMA mandates that physicians who order advanced diagnostic imaging services for Medicare patients, e.g. MRIs, must have their supporting clinical staff consult a qualified Clinical Decision Support Mechanism or qCDSM. The qCDSM determines if the service order adheres to Appropriate Use Criteria (AUC). If the order is placed without consulting with a (CDSM and thus outside of AUC) the service will subject to payment review and potential denial by Medicare.

Where does AUC come from? They are derived from evidence-based criteria such as those developed by the American College of Radiology (ACR).  For example, if a patient presents with a sore wrist, the new guidelines would prevent the physician from ordering an MRI first. To get reimbursed, the doctor has to use the qCDSM to state an ICD-10 code (diagnosis) that matches with a CPT code, which describes the procedure.

This may seem like a rather complex way to understand reimbursements. Unfortunately, this is the new, ironclad reality in medicine today. PAMA/qCDSM regulations call for penalties for practitioners who exhibit ordering patterns that are non-AUC-compliant “outliers,” in statistical terms. Being an outlier is going to mean reimbursement reviews and denials.

Overcoming obstacles to reimbursement

Order management software like iOrder now provides a complete solution to overcome obstacles to reimbursement. It gives patients and service providers the detail they need to make sure the service is delivered correctly the first time. This reduces the potential for repeat “do it right this time” services.

More significantly, iOrder now comes with qCDSM support. Using iOrder, the referring physician is guided by intelligent software to comply with AUC. The order will have the correct ICS10 and CPT codes. It will meet the criteria set out by the ARC. Service providers who use iOrder will face many fewer payment reviews and denials. Use of qCDSMs will become mandatory as of January 1, 2020. Claim denials for non-use of qCDSMs will start a year later. Now is the time to get out in front of these potential reimbursement problems. To learn more about iOrder’s reimbursement-advancing capabilities, visit