A 75-year-old woman presents in your medical practice with acute hip pain. She’s had a fall recently and worries that she may have a fracture. Until pretty recently, you could have ordered a CT scan or MRI for this patient and gotten reimbursement from Medicare without too many challenges. This is all changing now, due to new federal regulations governing imaging services and Medicare payments. Starting soon, it will be imperative for doctors to use approved diagnostic codes, based on The American College of Radiology (ACR) Appropriateness Criteria® (AC).

Background: The Mandate for qCDSMs

Under the Federal Government’s Protecting Access to Medicare Act (PAMA) of 2014, physicians who order CT scans, PET cans, MRIs and nuclear medicine services for their patients must have their support staffs use a qualified CDSM or qCDSM. A qCDSM is a “Clinical Decision Support Mechanism” approved by designated entities authorized (qualified) by the Federal government.

The qCDSM applies “appropriate use criteria” or AUC information to the order. This is meant to ensure that the doctor makes the most appropriate treatment decision for a given clinical condition. Orders not resulting from qCDSM consultation and will be subject to payment reviews and denials starting in January 2021. Medical order management systems like iOrder offer CDSM functionality. Some electronic health record (EHR) software packages do as well.

The ACR Appropriateness Criteria (AC)

The PAMA regulations recognize the ACR AC as AUC, for the purpose of qCDSM. Indeed, the Centers for Medicare & Medicaid Services (CMS) named the ACR to be a “qualified Provider-Led Entity” (qPLE). This means the ACR is approved to provide AUC in a qCDSM.

The ACs are evidence-based guidelines that assist referring physicians in ordering the right service for a particular condition.  They have been in use for over 20 years and have demonstrated improvements in results in terms of treatment quality and reduction in unnecessary imaging procedures.

It’s a very extensive set of guidelines. The criteria cover 215 topics and more than 1,080 clinical indications, all with the purpose of recommending the most appropriate medical imaging exam for a patient’s condition. A sampling of conditions covered by AC include Breast Cancer Screening, Breast Imaging of Pregnant and Lactating Women, Breast Implant Evaluation, Breast Pain, Evaluation of Nipple Discharge, Evaluation of the Symptomatic Male Breast and on and on. Each condition is accompanied by deeply researched, evidence-based reports.

Example of AC

Returning to our 75-year-old patient, when the physician consults the AC, he or she will find that radiography of the hip or pelvis (or both) is considered “Usually Appropriate” under the guidelines. A CT of the pelvis and hips with IV contrast, is “Usually Not Appropriate.” The AC reference includes, in this case, a 9-page report backing up the medical science behind this recommendation.

Getting the Coding Correct

iOrder can help you comply with the qCDSM mandate and get your coding right with the AC it includes. The online order management solution provides the capabilities you need to avoid billing denials and payment reviews after the deadline takes effect.

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