We’ve noted some confusion in the radiology field about the deadlines for compliance with new Federal regulations concerning the use of Qualified Clinical Decision Support Mechanisms (qCDSMs). We wanted to take a moment to clarify the deadline issues and delve a little bit into the background of the whole underlying change in regulations that created the deadlines in the first place.

Briefly, there actually two separate deadlines. One concerns the mandatory use of a qCDSM. The other relates to the start of new payment review practices by Medicare. The use of qCDSMs will become completely mandatory as of January 1, 2020. Radiology providers will subsequently begin to see claim denials related to qCDSMs and AUC starting on January 1, 2021. However, Now, let’s dig into what this all means, in practical terms.

Some Background on Clinical Decision Support Mechanisms (CDSM)

A Clinical Decision Support Mechanisms (CDSM) is a type of interactive software tool used by doctors to communicate compliance with what are known as “appropriate use criteria” or AUC information. The CDSM assists the doctor in making the most appropriate treatment decision for advanced imaging services for a given patient’s clinical condition. CDSMs are typically available through order management systems or electronic health record (EHR) software packages.

The PAMA Law and qCDSMs

In 2014, the US Congress passed, and the President signed, the Protecting Access to Medicare Act (PAMA) of 2014. PAMA covers a range of subjects related to Medicare. Section 218(b) of PAMA established a new program that would increase the proportion of appropriate advanced diagnostic imaging services being provided to Medicare patients. These included services like computed tomography (CT), positron emission tomography (PET), magnetic resonance imaging (MRI) and nuclear medicine.

Under the terms of PAMA, a doctor who orders an advanced diagnostic imaging service for a Medicare patient must have his or her supporting clinical staff consult a qualified CDSM or qCDSM. The purpose of the law is to require a doctor to pursue treatment that matches professionally validated, evidence-based criteria—in this case coming from the American College of Radiology (ACR).  Thus, if a patient presents with a sore wrist, the new guidelines would prevent the physician from ordering an MRI first, even if he or she wanted to. 

If the physician ordered an MRI for a sore wrist, without consulting the decision support tree and certifying the order (and further treatment), the physician wouldn’t get paid by Medicare. To comply, and get paid, the doctor has to state an ICD-10 code (diagnosis) that matches with its CPT code. CPT codes refer to procedures related to that doctor’s appointment.  This is the qCDSM mandate, with its two compliance deadlines.

A qCDSM provides a determination regarding whether a service order adheres to AUC. A qCDSM is a decision support mechanism approved by designated entities authorized by the Federal government. There are several approved qCDSMs now in operation.

The mandatory use of qCDSMs is being introduced incrementally. We are still in a trial phase. As of January 1, 2020, use of qCDSMs will be completely mandatory for medical practices that treat Medicare recipients. As of the 2020 deadline, Medicare will still allow for mismatches between ICD and CPT codes and ability to correct them. After the 2021 deadline, such inconsistencies will result in automatic payment denials. 

The PAMA/qCDSM regulations also call for penalties for practitioners who exhibit ordering patterns that are “outliers,” in statistical terms. This means that their orders for MRIs, for example, do not meet AUC. These doctors 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

iOrder and Integrated Decision Support

The qCDSM mandate will be here in six months. iOrder enables you to comply with this mandate. It  provides a complete order management system that integrates with a qCDSM through the Sage system.

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