As the latest addition to the Protective Medical Insurance Act (PAMA) passed by Congress in 2014, the Center for Medicare and Medicaid Services (CMS) initiated Appropriate Use Standard (AUC) Plan, Including the clinical decision support mechanism (CDSM). The directive requires subscription providers to consult the AUC software program when ordering advanced imaging tests, and then issue a compliance certificate to rendering providers so that they can be reimbursed by Medicare.
The AUC program is designed to support diagnostic doctors in ordering advanced imaging tests, but contrary to intuition, if they do not receive a compliance certificate directly from the ordering provider, it will affect the reimbursement of rendering doctors. Eighteen months have passed since the two-year education period, and many subscription providers are unaware of the new regulations that will take effect on January 1, 2022.
For providers who charge Medicare Part B, the impact on income can be significant. Radiology, cardiology, and orthopedics practices, as well as outpatient hospital facilities and imaging centers, will rely on subscribing suppliers, otherwise they will completely lose revenue. The only exceptions are inpatient services (billed for part A of medical insurance), emergency patients, and doctors with major difficulties (such as rural areas or lack of Internet access).
CDSM-What is it and how will it affect medical insurance reimbursement?
For referral providers who order advanced imaging tests (including MRI and CT), the new regulations require them to consult CMS-approved CDSM software through AUC to determine whether they need to be tested. If so, the software will generate and forward a compliance certificate, and forward it to the appropriate rendering provider.
This certificate is then saved in the patient’s medical record, and the result is encoded in the imaging claim sent to Medicare. This authorization creates a unique situation where the ordering supplier is responsible for consulting, but the rendering supplier is a supplier with reimbursement risk.
Which tests require AUC to consult a new authorization?
CDSM is required for the following advanced imaging tests:
- Computer tomography (CT)
- Magnetic resonance imaging (MRI)
- Nuclear medicine, and
- Positron Emission Tomography (PET)
When ordering advanced imaging tests for Medicare Part B patients, the ordering provider will need to consult a CMS qualified CDSM. The results of the AUC consultation are then forwarded to the rendering provider for inclusion in the Medicare reimbursement claim.
Has the new directive approved CDSM software or standards?
Yes, CMS manually selected a group of vendors to develop their own proprietary software to manage AUC standards and CDSM processes.For each approved supplier, CMS cooperates with AMA to publish Company-specific G code Used for claims reimbursement.
Can the existing system of record be integrated with the new CDSM electronic portal?
Yes, radiology, orthopedics, oncology, cardiology, sleep medicine and other majors will require CMS qualified CDSM software, which is specifically developed for use with qualified supplier lead entities (qPLE) to assist in diagnostic support . The CDSM software will seamlessly integrate with existing EMR/EHR/RIS systems.
Are all junior and professional providers affected by this?
Any provider that uses advanced imaging technology to diagnose Medicare Part B patients should comply with the CDSM-including primary care, radiology, cardiology, oncology, sleep medicine, pain medicine, and orthopedics.
The only exceptions are emergency situations, hospitalized patients who need to be tested (Medicare Part A), and providers who prove difficulties (such as inability to access reliable Internet services).have New HPCCS modifier For each of these situations. Rendering providers need to use appropriate modifiers on each statement to explain their situation.
For example, the modifier “MA” is used to indicate any suspected or confirmed emergency situations where the time does not allow the use of CDSM.
What happens if the compliance certificate is not forwarded to the rendering provider?
From January 1, 2022, rendering suppliers will be required to comply with CDSM requirements, otherwise they will face the risk of loss of revenue. Although CMS currently chooses to focus on outreach and education, there are plans to monitor and initiate the consequences for those ordering suppliers who refuse to comply with future authorizations.
What does the furniture supplier’s advanced imaging statement need to include to prove receipt of the compliance certificate?
Each claim requires these three values:
- CPT G code, specifying which CMS approved CDSM software vendor was used,
- Similar to prior authorization, there will be a unique consultation identification code, which is used to provide proof of consultation, and
- The HCPCS modifier will indicate whether the recommendation complies with the qPLE standard. If the standard indicates that the advanced imaging test is not within the scope of AUC, the ordering provider can continue the test, but must indicate on the certificate of conformity that their choice is not within the scope of the CMS guidelines.
Will the test be reimbursed even if the AUC is not complied with?
Yes, there is an HCPCS code indicating that AUC was consulted. If there is a clear out-of-scale pattern (not yet determined), the rendering provider will be compensated for the program, and the subscription provider may face monetary impact in the future.
Are the doctors ready for the new CDSM instructions?
Whether they are unaware of the new instructions or unwilling to participate, many ordering and rendering vendors are simply not ready for January 2022. American College of Radiology (ACR), It has fallen to provide providers with basic education for their ordering doctors through outreach and professional education.
How can furniture suppliers support ordering suppliers through this change?
Through advanced automation and machine learning, there is software that can ease the burden on ordering and furniture suppliers. The best option is the CDSM solution from an approved supplier, which can send a link to the furniture supplier to generate an email for CDSM inquiries to the ordering supplier. Then, the ordering provider (or its designated person) can generate a certificate and return a copy to the rendering provider in real time.
in conclusion
Although CMS took the lead in carrying out large-scale information campaigns, many providers did not understand CDSM and the new CMS directives. Active radiology teams and hospital-supported outpatient systems have been providing outreach programs to educate ordering doctors on the use and importance of the new CDSM software option.
However, in the future, CMS may require non-compliant suppliers to obtain additional approvals with a high percentage of non-compliance procedures, such as prior authorization, or face financial risks.
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