Gone are the days when a doctor could simply dash off an order for a procedure and let the billing department take care of the details. The healthcare industry has now embraced a bundle of processes, rules and technologies for Decision Support. These are methods of ensuring that a service is required—and will be reimbursed—according to the payer’s guidelines. Decision support is particularly relevant in radiology, where services tend to be costly.

Now, with the promulgation of new regulations under the US Federal Government’s Protecting Access to Medicare Act (PAMA) of 2014, decision support is becoming totally mandatory for Medicare for certain procedures.  Order management solutions must be compliant with qualified decision support systems in order to ensure a high standard of care and no unnecessary procedures as well as proper reimbursements.

What is a Clinical Decision Support Mechanism (CDSM)?

Clinical Decision Support Mechanisms (CDSMs) are interactive software tools that doctors use to communicate their compliance with what are known as “appropriate use criteria” or AUC information. The goal of CDSMs is to assist the doctor in making the most appropriate treatment decision for a given patient’s clinical condition. CDSMs are usually available through order management systems or electronic health record (EHR) software packages.

Where the Law is Going on This Issue

By means of Section 218(b) of the PAMA law, a new program was established to increase the proportion of appropriate advanced diagnostic imaging services being provided to Medicare patients, e.g. computed tomography (CT), positron emission tomography (PET), magnetic resonance imaging (MRI) and nuclear medicine.

Under PAMA, when a doctor orders an advanced diagnostic imaging service for a patient who is covered by Medicare, the supporting clinical staff is required to consult a qualified CDSM or qCDSM. The CDSM gives a determination about whether the service order adheres to AUC. This rule is being introduced slowly. Right now, in 2019, the healthcare industry is in a trial phase. Use of qCDSMs will become completely mandatory for medical practices that treat Medicare recipients in 2021.

The PAMA/qCDSM system includes penalties for practitioners who demonstrating ordering patterns that are “outliers,” in statistical terms, in their ordering of services. Such physicians will become subject to prior authorization. There will also be non-reimbursement penalties for services that do not meet AUC.

The program affects all physicians and practitioners who order advanced diagnostic imaging services. It also covers imaging service providers like hospital and other facilities. This includes doctor’s offices that offer such services as well as hospital outpatient departments, e.g. the emergency room. Ambulatory surgical centers and independent diagnostic testing facilities (IDTFs) also come under these regulations.

Integrated Decision Support

The coming mandate for qCDSM creates a requirement that any service order management system contain a qualified CDSM. iOrder does this, enabling users to order the most appropriate exam the first time through integrated decision support. This serves to maximize reimbursements and speed patient throughput.

To learn more about iOrder’s CDSM capabilities, visit http://iprohealthcare.com/