Effective collaboration with your referring physicians can make the difference between getting paid or not getting paid. Cooperation between referring and ordering professionals becomes increasingly important with the approaching implementation date for the Protecting Access to Medicare Act, on January 1, 2020. Radiology groups that proactively align with hospitals and referring clinicians to jointly implement and develop clinical decision support mechanisms (CDSMs) will likely see greater success in the long run.
Appropriate Use Criteria Essential to Compliance
The Protecting Access to Medicare Act of 2014 (PAMA) amended the Social Security Act to direct Centers for Medicare & Medicaid Services (CMS) to establish appropriate use criteria (AUC) for advanced diagnostic imaging services. Complete information—in excruciating detail—is available from the CMS AUC Program website.
I suggest starting with a more palatable overview of the program, presented in a recently recorded webinar Avoid Payment Denial: Key Steps to Prepare for AUC. In it, I highlight some of the key CMS terminology, requirements and deadlines that are impacting radiology practices today and will for the foreseeable future.
To navigate the complex AUC program effectively requires the use of technology in the form of CDSMs, digital tools that guide referring physicians to the appropriate imaging for each patient.
CDSMs are somewhat useful as standalone applications for direct entry of patient information, but may provide significant insight when integrated with more comprehensive data from electronic health records (EHR) and other sources. CDSMs can provide more clearly-defined context – e.g. specific patient characteristics, laboratory results, lists of co-morbid diseases – for each interpretation. From a practical standpoint, integrating EHR and other patient data will lessen the time clinicians spend using the tool.
Keep in mind, PAMA does not allow furnishing professionals (radiologists) to consult in lieu of or in the absence of consultation by ordering professionals. Radiology groups may want to consider integrating a CDSM portal into their online ordering systems to allow ordering physicians to submit imaging orders and consult a CDSM seamlessly.
Choosing Your CDSM
First, use a qualified CDSM (sometimes abbreviated qCDSM)—one that has been certified as meeting CMS requirements under the Social Security Act. A list of qCDSMs is available on the CMS website. From this list, evaluate alternative systems based on their fit with your current practice and processes. Here is a checklist of areas and features to consider when assessing alignment.
- Ordering patterns and clinical practices
- AUC needed by specialty of ordering professional
- AUC related to priority clinical areas
- Available integration with your EHR
- Radiologist access to patient information and data entered by the ordering physician
- Potential system customization options to ensure better fit
- Required or enhanced analytics capabilities
- Automatic population of order data fields to streamline modifications
- On-demand access to guideline details
- An interface that is easy to use, minimizing training requirements and learning curves
It is unlikely you will find a CDSM to align precisely with your current processes, not to mention those of your referring hospital systems and clinicians. However, the goal in selecting a CDSM is to help ensure compliance, so you get paid in a timely fashion, while minimizing disruption to your current operations and limiting the cost of compliance.
The good news: Ultimately, the right CDSM may enhance the performance of your radiology practice through process efficiencies and advanced analytic tools.
About the Author
Sharon Roeder, BA, CPC, Director of Medical Coding Compliance, vRad. Certified Professional Coder since 1999, member, American Academy of Professional Coders. Bachelor’s degree in business administration, Ottawa University. Certification, Harold P. Freeman Institute for Patient Navigation.