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.

Tell Your Congressperson to Co-sign CMS Med Advantage Prior Authorization Guidance Letter

Prior authorization in Medicare Advantage plans continue to burden medical practices with unnecessary paperwork and place barriers to care for Medicare patients. This issue has gotten the attention of two physician members of congress, Reps. David Roe, MD (R-TN) and Ami Bera, MD (D-CA), who have drafted the attached letter to provide guidance and support to CMS for improving the system of prior authorization used by Medicare Advantage plans.

The MGMA Government Affairs office is encouraging you to contact the district offices of your representatives to request that they co-sign this letter. Time should be given to helping representatives, and importantly their staff, understand the pain points surrounding prior authorization for medical groups. As such, here are some helpful talking points that you could use when speaking to staff (but real life, concrete examples on how this issue impacts your practice are best!):

  • As a medical practice leader, I regularly see the real-world impact on patients who encounter barriers to timely care that are caused by onerous and often unnecessary prior authorization requirements. Not only do these requirements delay care, they are often approved because Medicare Advantage plans are ultimately required to provide equivalent coverage to fee-for-service Medicare, which generally does not require pre-approval for services. Therefore, plans are precluded from using prior authorization to inhibit access to services.
  • As a member of the Medical Group Management Association, and one of your constituents, I urge you sign-on to this letter and show support for reducing needless prior authorization requirements that interfere with a patient’s care.

The attached letter is planned to be delivered to CMS in September and it is paramount that it be delivered with wide support. Please also remember to make use of the Legislative Liaison Member Community to continue this advocacy discussion. As always, I and the rest of the MGMA Government Affairs team are happy to discuss more with you the contents of the letter and the issue of prior authorization within Medicare Advantage. Please do not hesitate to reach out at any time with questions.

Warmly,

Mollie Gelburg
Associate Director, Government Affairs
MGMA
1717 Pennsylvania Ave NW #600
Washington, DC 20006
202.293.3450
mgelburd@mgma.org

Can I Text My Patients? FAQs – Emails and Texts

By Carrie Lowe, JD

2018 Alliance sponsor feature article courtesy of MagMutual

Can I text or email my patients?

Yes, healthcare providers can communicate with patients via text messages, but only if:

  1. The communication is encrypted or sent via a secure messaging system, or
  2. The patient is warned beforehand regarding the risk associated with unencrypted communication and the patient still prefers to communicate via unsecured text or email.

If a provider sends an email or text message that is encrypted or sent over a secure messaging system, such as a secure patient portal, the message may include protected health information (PHI). The Department of Health & Human Services (HHS), in its Guide to Privacy and Security of Electronic Health Information, points out that if a provider uses an EHR system that is certified under ONC’s 2014 Certification Rule, the EHR should have the capability to allow patients to communicate through a secure patient portal. However, patients may want information sent via text to their phone or personal email account, which is not secure or encrypted, rather than going to a portal.

Patients have a right to receive communications (including PHI) from the provider by alternative means, such as email or text.[i] However, it is incumbent upon the healthcare provider to inform the patient, in writing, of the risk of unintentional disclosure to a third party of PHI if sent in an unsecure manner. If the patient, after being informed of the risks, chooses to communicate via unsecured means, the patient has that right. This can be done by discussing these risks with the patient and having the patient sign a consent form acknowledging that he or she understands the risk.

In the Final Omnibus Rule, the HHS Office for Civil Rights (OCR) states that covered entities are not required to educate individuals about encryption and information security, but must notify the patient that there is a risk that the information in the email could be read by a third party. “If individuals are notified of the risks and still prefer unencrypted email, the individual has the right to receive protected health information in that way, and covered entities are not responsible for unauthorized access of protected health information while in transmission to the individual based on the individual’s request.” [ii]

What if a patient sends an unsolicited text to me?

When a patient initiates communication with a provider by email or a text message, the provider can assume that email or text is an acceptable form of communication to the patient. A patient may send health information to a healthcare provider using an unsecure email or text. Once this health information is received by the provider, however, it becomes PHI. At that point the PHI must be safeguarded and any texts back to the patient must be sent via a secure messaging system, encrypted, or the patient must have been previously warned in writing of the risk, with supporting documentation that shows that the patient accepted the risk.

Can I send texts regarding patient care to other healthcare providers?

Yes, you can send PHI to other healthcare providers, but only if the information is sent via a secure messaging system or is encrypted.

Can I text orders to members of the healthcare team?

No, CMS and the Joint Commission explicitly prohibit healthcare providers from texting orders. In addition to the privacy and security concerns discussed above, there is concern that the information may be lost or compromised if it has to be manually entered into the medical record from a text message. Other healthcare providers will not have access to the order if it is not in the medical record, which could affect patient care. The medical record must contain all information upon which treatment decisions are based, and patients have the right to access this information pursuant to HIPAA. The recent CMS Memorandum can be found here.
[i] 45 C.F.R. 164.522(b)

[ii] 78 Fed. Reg. 5634

Issue Spotlight: Proposed Changes to Medicare E&M Visits

Originally published in the July 18, 2018 issue of MGMA’s Washington Connection
Reprinted with permission from MGMA

The Centers for Medicare & Medicaid Services (CMS) released the 2019 Medicare Physician Fee Schedule proposed rule that would affect Medicare physician reimbursement policies beginning in 2019. Among other changes, CMS proposes to:

  • Collapse evaluation and management (E&M) Levels 2-5 into one level for new patients and another for established patients. The average national payment would be $135 for new patients and $93 for established patients.
  • Allow clinicians to choose to document office and outpatient E&M visits using medical decision-making or time or continue using the current 1995 or 1997 E&M documentation guidelines.
  • Create a minimum documentation standard so clinicians would only need to meet requirements currently associated with a level 2 visit for history, exam, or medical-decision making (except when using time to document the service).

To help MGMA evaluate the impact of these proposed changes and advocate on behalf of medical group practices, please share your feedback on these proposals by filling out this brief comment form.

MLN Connects: Thursday, February 15, 2018

MLN Connects is the official news source of the Medicare Learning Network (MLN). Here is the latest news, posted February 15, 2018. Click on the header links for detailed information about each bullet item.

News & Announcements

  • MIPS Reporting Deadlines Fast Approaching: 10 Things to Do and Know
  • Quality Payment Program: Performance Scores for 2017 Claims Data
  • Diabetic Self-Management Training Accreditation Program: New Webpage and Helpdesk
  • Measures of Hospital Harm: Comment by February 16
  • EHR Incentive Program: Accepting Proposals for New Measures by June 29
  • New Option for Submission of Medicare Cost Reports

Provider Compliance

  • Home Health Care: Proper Certification Required — Reminder

Claims, Pricers & Codes

  • January 2018 OPPS Pricer File

Upcoming Events

  • Improving Accessibility of Provider Settings Webinar — February 21
  • ESRD QIP: Final Rule for CY 2018 Call — February 22
  • 2018 QCDR Measures Workgroup Webinar — February 27
  • Serving Adults with Disabilities on the Autism Spectrum Webinar — February 28
  • MIPS Quality Data Submission Webinar — February 28
  • Palliative and Hospice Care for Adults with Disabilities Webinar — March 7
  • Low Volume Appeals Settlement Option Update Call — March 13
  • Open Payments: The Program and Your Role Call — March 14
  • MIPS Attestation for Advancing Care Information and Improvement Activities Webinar — March 14

Medicare Learning Network Publications & Multimedia

  • Medicare Enrollment Resources Educational Tool — Revised
  • PECOS FAQs Booklet — Revised
  • PECOS for DMEPOS Suppliers Booklet — Revised
  • Safeguard Your Identity and Privacy Using PECOS Booklet —Revised
  • PECOS for Provider and Supplier Organizations Booklet — Revised
  • PECOS Technical Assistance Contact Information Fact Sheet — Revised
  • Health Professional Shortage Area Physician Bonus Program Fact Sheet — Revised
  • Medicare Secondary Payer Booklet – Reminder
    Beneficiaries in Custody under a Penal Authority Fact Sheet — Reminder

MLN Connects: Thursday, February 1, 2018

MLN Connects is the official news source of the Medicare Learning Network (MLN). Here is the latest news, posted February 1, 2018. Click on the header links for detailed information about each bullet item.

News & Announcements

  • Medicare Diabetes Prevention Program: Supplier Enrollment Open
  • Targeted Probe and Educate: New Resources
  • MIPS Clinicians: 2017 Extreme and Uncontrollable Circumstances Policy
  • Quality Payment Program: Patient-facing Encounters Resources
  • Eligible Hospitals and CAHs: Get Help with Attestation on QNet
  • Find Medicare FFS Payment Regulations
  • February is American Heart Month

Provider Compliance

  • Cochlear Devices Replaced Without Cost: Bill Correctly — Reminder

Upcoming Events

  • eCQM Reporting for Hospital IQR-EHR Incentive Program Webinar — February 6
  • Low Volume Appeals Settlement Option Call — February 13

Medicare Learning Network Publications & Multimedia

  • Next Generation Accountable Care Organization – Implementation MLN Matters® Article — Revised
  • DMEPOS Quality Standards Educational Tool — Revised
  • Home Oxygen Therapy Booklet — Revised
  • Looking for Educational Materials?

February 5th CMS Webinar: The Merit-based Incentive Payment System (MIPS)

The Merit-based Incentive Payment System (MIPS):
Annual Call for Measures and Activities

February 5, 2018
2:30 PM – 3:30 PM ET

The Annual Call for Measures and Activities process allows clinicians and organizations, including but not limited to those representing eligible clinicians such as professional associations, and medical societies, and other stakeholders such as researchers and consumer groups to identify and submit for consideration:

  • Quality measures for the quality performance category;
  • EHR measures for the advancing care information performance category; and
  • Activities for the improvement activities performance category.

To register for this webinar, please follow this link:
https://engage.vevent.com/index.jsp?eid=3536&seid=997