Reminder: 2020 Only a Testing Year for AUC

Originally published in the January 16, 2020 issue of MGMA’s Washington Connection
Reprinted with permission from MGMA

Some medical group practices have been told to immediately purchase and use Clinical Decision Support Mechanism (CDSM) software to comply with the Appropriate Use Criteria (AUC) program, with vendors suggesting that claims payment would be impacted in 2020. In a posting on its website, the Centers for Medicare & Medicaid Services (CMS) reiterated that 2020 is an educational and operational testing period and there are no payment consequences this year.

The AUC program will require ordering professionals to consult CDSM software for certain advanced imaging tests and require rendering professionals to include that consultation code on their Medicare claims starting in 2021. Practices are encouraged, however, to plan for implementation of CDSM software and test workflows at some point this year. Access the MGMA AUC Toolkit for additional information on the program.

Start Strong in 2020: Important Dates for Physician Practices

Originally published in the December 19, 2020 issue of MGMA’s Washington Connection
Reprinted with permission from MGMA

Transitioning to a new year means important federal program deadlines and launches. Below are key dates that executives should know as they prepare their medical practice for success in 2020.

DEC. 31

• Check MIPS 2019 eligibility by year’s end
  Clinicians are encouraged to confirm their 2019 Merit-based Incentive Payment System (MIPS) eligibility status by using the QPP Participation Status Tool to determine whether they must report data in 2020. The Centers for Medicare and Medicaid Services (CMS) recently concluded its second review of Part B claims and PECOS data spanning Oct. 1, 2018 through Sept. 30 of this year.
• Deadline to submit MIPS hardship and exception application
  Promoting Interoperability and Extreme and Uncontrollable Circumstances Exception applications for the MIPS 2019 performance year must be submitted by Dec. 31. MIPS participants in FEMA-designated disaster areas are automatically exempt from reporting and will have all four performance categories re-weighted to 0% of their final score.
• Deadline to review and dispute program year 2018 Open Payments data
  Visit the CMS Open Payments website to review data submitted from drug and device manufacturers describing any payments made to physicians in your practice. Clinicians have until the end of the year to dispute any incorrect information.

JAN. 1

• New 2020 Medicare payment rules and MIPS requirements
  The 2020 Physician Fee Schedule begins, which includes payment updates for Medicare services, changes to billing guidance for certain codes, and modifications to reporting requirements under MIPS. These details are outlined in MGMA’s member-exclusive analysis.
• Use of MBI on Medicare claims starts
  Starting Jan. 1, Medicare claims are required to contain the Medicare Beneficiary Identifier (MBI) in order to be processed. For patients who do not present with their new card, practices can get their MBI via your Medicare Administrative Contractor. Members can access the MGMA New Medicare Card Toolkit to prepare for the transition.
• AUC education and testing period begins
  Jan. 1 marks the start of the one year educational and operations testing period for the CMS Appropriate Use Criteria (AUC) program. Download the member-benefit AUC Toolkit to learn more.

JAN. 2

• MIPS 2019 data submission period starts
  2019 MIPS performance data can be submitted to CMS from Jan. 2 through March 31. Authorized representatives can submit clinician and practice data via the QPP webpage.

JAN. 22

• Close of Primary Care First and Kidney Care Choices application period
  Jan. 22 is the deadline to apply for the Primary Care First (PCF) Model and Kidney Care Choices (KCC) Model. PCF will be offered in 26 geographic regions starting in 2021, and the KCC Implementation Period will begin later in 2020. MGMA will share links to several informative resources prior to the deadline for practices seeking to understand whether these models are right for them.

Clinical Decision Support Mechanisms (CDSM)

You know that can you’ve been kicking down the road?
Well, don’t look now but it’s starting to roll back!

by John Lillie, Senior Strategic Accounts Manager, CMS Imaging, Inc.

And it’s more like a 55-gallon drum that is slowly picking up speed.

Clinical Decision Support Mechanisms (CDSM) utilize Centers for Medicare and Medicaid Services (CMS) approved Appropriate Use Criteria (AUC). These CDSMs must be consulted prior to completing an order for either CT, MRI, Nuclear Medicine, or PET studies for Medicare outpatients in any non-inpatient place of service. CMS has targeted reporting for eight clinical areas to identify outlier physicians:

• Coronary artery disease (suspected or diagnosed)
• Suspect pulmonary embolism
• Headache (traumatic or non-traumatic)
• Hip Pain
• Low Back Pain
• Shoulder Pain (to include suspect rotator cuff injury)
• Cancer of the Lung (primary or metastatic, suspected or diagnosed)
• Cervical or neck pain

Ordering providers don’t have to abide by what was shown to be the best imaging modality; they must only demonstrate that they consulted AUC through an approved mechanism. Failure to consult an approved AUC will cause the professional and technical component reimbursement to be denied – as in zero-dollar reimbursement. That should get your attention.

The goal is admirable: reduce the number of inappropriate exams, which would improve the quality of healthcare by reducing dose where applicable. Good for the provider and good for the patient. However, as always, the devil was, and still is, in the details.

Originally slated to go in effect on January 1, 2016, this initiative has been delayed time and time again, and thankfully so. Neither CMS, nor the providers, nor the industry was prepared to implement these standards. Like peeling away the layers of an onion, the deeper reasonable interests investigated the topic, the more challenges became apparent. Available space to devote to the resultant coding is an issue, for example.

Moreover, what about those providers who still use the fax machine or paper orders? How are we going to get all providers, regardless of their specialty or size, to do this? These are real-world challenges.

A more significant challenge is that not everyone knows enough about the AUC consultation requirement, the approved mechanisms, and all of the other details, and are nowhere close to implementing a workable solution. Plus, there is no funding mechanism provided externally to help you to comply with the mandate. Assuming you have addressed this, I am quite sure that this was a pleasant conversation for radiology managers to have with their CFO’s (I sincerely hope you’ve had these conversations, right?). Apparently, many have not.

In a recent survey conducted by the Association for Medical Imaging Management (AHRA), among the 291 total responses who responded to the question “Have you implemented or begun implementing Clinical Decision Support (CDS)?”, 35% responded Yes, 61% responded No, and 3% were not sure what CDS is (Source: Regulatory Affairs: Clinical Decision Support (CDS) 05/2018 Survey, released on July 5,2018).

The good news is that since the passing of PAMA 2014, healthcare entities have far more choices available today as to which CDSM they would like to consider. The list of qualified Provider-led Entities (qPLE) who have been approved to “develop, modify, or endorse” Appropriate Use Criteria (AUC) are growing as well (see the list at the end of this blog posting). Newly approved qPLE’s are announced each June. The industry around Clinical Decision Support for Medical Imaging is growing. More choices allow for more informed decisions. More options will enable the marketplace to reward those who succeed and punish those whose products don’t pass muster.

What is a more significant concern, now that the mandate has been pushed back to January 1, 2020, is will the industry still be ready? The first year will, in effect, be an educational and operations testing period, but full compliance will be the standard for the second year. It is my concern that this reality has not become real. According to Sheila M. Sferrella, MAS, RT(R), CRA, FAHRA, Chair of the AHRA Regulatory Affairs Committee and President of Regents Health Resources, “It typically takes 12-18 months to implement a program like AUC in a hospital setting. Budgeting, funding, IT interfaces, RFP or vendor selection, and then implementation. This regulation is the most challenging one we have had to implement on the hospital side because we have to make sure we capture the AUC code from the referring physician so that the hospital gets paid and then somehow transfer that information to the radiologist’s professional group for payment. It includes hospital bling forms and physician billing forms where codes do not necessarily populate in the same place. The AHRA (The Association for Medical Imaging Management) is working with a group of industry leaders to find a solution that is electronic and not manual. We are trying to help our members prepare for implementation.”

The AHRA has been at the forefront of working with the CMS and their members to find a solution. I count myself as a member of this organization, and I applaud their actions on this front.

It is vitally important that the radiology industry examine, explore, and make their voices heard on the selection of the best CDSM for their facility. They should lead the charge on selection because it is their world that bears the responsibility for it to work. Moreover, they will be the ones penalized if they do not implement the change.

The can that was kicked is now rolling back. According to Ms. Sferrella, the likelihood that this initiative will be again kicked down the road is “almost none.” While some may have hoped this would happen, or the initiative will die and go away, that is not going to happen.

In summary, it is always a better outcome to plan and prepare before a crisis hits. Acting at the last minute, deciding and implementing a CDSM to make the deadline, usually results in panic buying and a whole lot of stress. There is still time, but it is running out faster than you think.  January 1, 2020, is now just 12 months away.

Approved qPLE’s as of this writing:

• American College of Cardiology Foundation
• American College of Radiology
• Banner University Medical Group-Tucson University of Arizona
• CDI Quality Institute
• Cedars-Sinai Health System
• Intermountain Healthcare
• Massachusetts General Hospital, Department of Radiology
• Medical Guidelines Institute
• Memorial Sloan Kettering Cancer Center
• National Comprehensive Cancer Network
• Sage Evidence-based Medicine & Practice Institute
• Society for Nuclear Medicine and Molecular Imaging
• University of California Medical Campuses
• University of Utah Health
• University of Washington School of Medicine
• Virginia Mason Medical Center
• Weill Cornell Medicine Physicians Organization

2018 Alliance sponsor article provided courtesy of CMS Imaging, Inc.  For more information, please contact John Lillie of CMS Imaging, Inc. – jlillie@cmsimaging.com.