The Protecting Access to Medicare Act (PAMA) was signed into law on April 1, 2014. It mandated all physicians and ordering professionals in the Medicare program to consult with a qualified Clinical Decision Support (CDS) software based on appropriate use criteria (AUC) for ordering advanced imaging studies such as diagnostic MRI, CT and nuclear medicine or PET services.

The implementation deadline for the CDS program was originally set for January 1, 2017. However, the Medicare Physician Fee Schedule released on October 30, 2015, noted that the Centers for Medicare and Medicaid Services (CMS) will delay the deadline. According to AuntMinnie’s Erik L. Ridley, “CMS indicated that it now doesn’t expect to have approved CDS ‘mechanisms’ until approximately the summer of 2017. The agency said it was not yet in a position to predict the exact timing of a new deadline for when practitioners are expected to begin utilizing clinical decision support.” CDS will still happen; it is still the law of the land. It will just happen later. Reaction to the postponement has ranged from disappointment to relief.

According to Radiology Business, exams that take place in physician offices, hospital outpatient centers or emergency departments will require consultation of AUC of advanced diagnostic services such as MRI, CT and nuclear medicine, including PET. The exams are exempt for inpatient imaging, emergency services as defined under the Emergency Medical Treatment and Active Labor Act (EMTALA). X-ray, fluoroscopy and ultrasound exams will not require AUC/CDS.

CDS advocates disappointed

One advocate for CDS, the American College of Radiology (ACR), has voiced disappointment and concern for Medicare recipients especially. According to Dr. Geraldine McGinty, chair of ACR’s Commission on Economics, “We engaged with [CMS] multiple times since then, understanding that this is a new paradigm and new program for them and really wanting to help them as much as we can.” McGinty continued, “We feel it is absolutely doable to have that implemented at the original date of January 1, 2017, so obviously we’re disappointed to see Medicare beneficiaries not getting the benefit of this quality tool when they were originally supposed to.”

McGinty explains that the alternative to software-based clinical decision support is radiology benefits managers. “If this delay provides an opportunity for (radiology benefits managers] to be the solution and not clinical decision support, that would be very unfortunate for [Medicare] beneficiaries,” said McGinty.

Relieved about the postponement

The Association for Medical Imaging Management (AHRA), has stated relief about the compliance date push back. In a blog posted on November 4, 2015, Sheila M. Sferrella, CRA, FAHRA, chair of the AHRA Regulatory Affairs Committee, writes that while AHRA members do not disagree with the endpoint of meeting the AUC/CDS consultation requirements, the deadline of January 1, 2017 doesn’t allow enough time to do it right.

Sferrella writes, “If you do the preparatory work and go a bit slower, you avoid downstream mistakes and workarounds. In my humble opinion, we are seeing the consequences of trying to do too much, too fast with lots of other policies (can you say EHR Meaningful use and inter-operability!).

One small example is that there is supposed to be a hashtag that will cross interfaces to billing. This has only been considered for a HCFA 1500 bill. No one has thought about the UB04 form which is used for hospital billing. AHRA has raised this issue with the e-Ordering Coalition and is working with HFMA and the committee that approves what goes onto the HCFA and UB billing forms. That is just one issue we have identified.”

Some points to consider

When CDS eventually happens, physicians who provide advanced imaging services such as CT, MRI, nuclear medicine and PET will only be paid if claims for reimbursement confirm that the appropriate use criteria was consulted, which CDS system was used, and whether the exam adhered or did not adhere to an acceptable CDS rating. AUC will have to be government-approved and evidence-based as established by a CDS software system. Note that while physicians do not necessarily have to adhere to the AUC, they must confirm that the guidelines were consulted.

Final Thoughts | CMS Delays Deadline for Clinical Decision Support Implementation

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