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Clinical Decision Support Mechanisms

The Can Kicked Down the Road

The Can Kicked Down the Road

I have a riddle for everyone. What am I?

I was supposed to start in 2018; then I was postponed until 2019; then I was delayed again until 2020. Now I must be implemented by January 1, 2020.

I am the Protecting Access to Medicare Act of 2014 (PAMA) mandate that states all diagnostic medical imaging which, billed to Medicare, will be run through a Clinical Decision Support Mechanism (CDSM). CDSM is a software that will review all imaging orders by using pre-established Appropriate Use Criteria (AUC) and will decide whether the imaging is "appropriate," "maybe appropriate," or "rarely appropriate." While currently, to receive Medicare reimbursement, a physician need only to prove that they consulted the AUC, going forward they will have to use a CDSM to provide that proof. To bill Medicare as of 2020, the confirmation code from the CDSM will be necessary for reimbursement. Without this confirmation code, the entity that ordered the imaging will not receive reimbursed.

Though January 1, 2020, is the official start of this part of PAMA, it is in actuality a soft-start. While Medicare will require this code at the beginning of the New Year, they will not reject the claims until 2021.

Originally added to PAMA to fight against unnecessary medical imaging, physicians and other ordering professionals now are concerned that the implementation of a CDSM software will be costly and cumbersome to their practices. More than two dozen medical professional societies* have joined together to petition the US Congress to re-examine the CDSM mandate. While they acknowledge the benefits of AUC in the care of their patients, they are concerned that the use of a CDSM will dictate the care of their patients without taking into account the unique circumstances of the medical imaging order. As the AUC is developed by a different set of medical professionals or as CMS (not our your favorite imaging provider) refers to them, Provider-Led Entities (PLE's)**, this becomes an extremely complicated issue. In essence, one set of professional societies is seeking a modification in the law to allow them more flexibility in AUC's set forth by another group of professional medical organizations.

(Phew, that's a lot of acronyms!)

Another piece to the puzzle, are the exceptions to the mandate that all imaging must consult the AUC for reimbursement.

  • Imaging services for inpatients paid for with Medicare Part A
  • Emergency medical conditions whereby a delay could cause harm
  • Orders made by physicians who obtain an exception due to significant hardship
    • insufficient internet connectivity
    • extreme and uncontrollable circumstances
    • lack of control over the availability of Certified EHR Technology
    • lack of face-to-face patient interaction

While this may sound confusing and unsettled, many physicians believe there should be another extension to the implementation of CDSM, but as of August 20, 2019, there appears to be no extension on the horizon.

So what do we have to do to comply?

The first point of business in compliance is to find a Centers for Medicare and Medicaid Services's approved CDSM. As of June 2019, there are fifteen qualified CDSMs***. To be qualified, the CDSM must meet stringent requirements. These include, but are not limited to:

  • AUC's for all eight Priority Clinical Areas****
  • Support AUC's from more than one PLE
  • Make AUC and supporting documentation available to ordering professionals
  • Must indicate which AUC was consulted if multiple apply
  • Meet HIPAA-compliant privacy and security standards.

While this all seems complicated and confusing, the bottom line is that January 1, 2020, is less than six months away. Proper research, purchase, implementation, and adoption will take longer than the six months until the mandate becomes active. Starting the process now may not have your practice up and running on New Years Day 2020, but it will ensure that your reimbursements continue on New Years Day 2021.

For more information on how CDSM works and how it can be implemented in your practice, visit our page for MedCurrent.

  • *Click to view list of Professional Medical Societies petitioning the US Congress to re-examine the CDSM mandate
    • Alliance of Specialty Medicine
    • American Academy of Family Physicians
    • American Academy of Neurology
    • American Academy of Orthopaedic Surgeons
    • American Academy of Otolaryngology-Head and Neck Surgery
    • American Academy of Physical Medicine and Rehabilitation
    • American Association of Neurological Surgeons
    • American College of Cardiology
    • American College of Obstetricians and Gynecologists
    • American College of Osteopathic Surgeons
    • American College of Physicians
    • American College of Surgeons
    • American Gastroenterological Association
    • American Medical Association
    • American Osteopathic Association
    • American Society for Dermatologic Surgery Association
    • American Society for Gastrointestinal Endoscopy
    • American Society for Surgery of the Hand
    • American Society of Nuclear Cardiology
    • American Society of Plastic Surgeons
    • American Urological Association
    • Association of Black Cardiologists
    • Cardiovascular Advocacy Alliance
    • Congress of Neurological Surgeons
    • Heart Rhythm Society
    • Medical Group Management Association
    • National Association of Spine Specialists
    • Society for Cardiovascular Angiography and Interventions
  • **Click to view list of Provider-Led Entities
    • 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 and 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 Organizations
  • *** List of Qualified CDSM
  • **Click to view list of Eight Priority Clinical Areas
    • 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