RADIOLOGISTS: URGENT: The latest on Appropriate Use Criteria and Clinical Decision Support

As a Radiologist, are you the least bit nervous for January 1, 2018 to arrive?  Does 100% of MEDICARE PAYMENT DENIAL get your attention?  Are your fellow referring physicians aware how this date will impact you and/or your practice?  Are you familiar with the latest Buzz Words………. Appropriate Use Criteria (AUC) and Clinical Decision Support (CDS).  Both will become common use terms, thanks to Medicare’s rule which requires the use of AUC and CDS in just a few short months.  Effective January 1, 2018, Medicare can deny radiologists’ payment, IN FULL, if the referring/ordering physician orders certain advanced imaging exams, without the appropriate use of the CDS system. Unfortunately, this is not something that impacts your fellow ordering physician, and instead only affects the radiologist and the facility where the radiology exam is performed.

100% of the payment denial will apply to BOTH the professional and technical components of the service.  Billing globally or separately will not hinder this penalty. And since there is no penalty, whatsoever, to the ordering physicians who fail to consult and document the use of AUC, you can expect radiology groups, hospitals and IDTF’s to ban together in their effort to develop a system requiring ordering physicians usage of AUC.

As a part of the Protecting Access to Medicare Act (PAMA), of 2014,  the Medicare regulation requires all ordering providers utilize Appropriate Use Criteria (AUC) when ordering certain advanced imaging exams, which include CT, MR, PET and certain nuc med exams for Medicare patients.   It is the responsibility of the radiologist to report the usage of CDS, and if the ordering physician fails to use the system, it will be the radiologist and the facility whose payment will be denied, in its entirety.  The first thing that comes to mind is that even though this is limited to Medicare (for now), it won’t be long before other major payers follow suit.

Exams provided on an “In-Patient” billed as Part A Medicare, or patients being treated on an Emergency Basis are the only exams exempt from this rule.  The requirement of consultation with AUC will apply to all other (specified) exams performed as “Out-Patient” and/or “IDTF”, billed as Part B Medicare.

July 2017-December 2017 is the designated short time span in which Imaging providers will have to acquire and implement a system and train ordering physicians on usage of the system.  Why such a short time frame? Because the list of qualified Clinical Decision Support Mechanism (CDSM), “an interactive, electronic tool for use by clinicians that communicates AUC information to the user and assists them in making the most appropriate treatment decision for a patient’s specific clinical condition.” The CDSM tool can be either an integral part of an existing electronic health records system or a stand-alone system, as long as it is certified by the Centers for Medicare and Medicaid Services (CMS) as a qualified system. systems will not become available until June 30, 2017. Remember, denial of payment is expected to begin January 1, 2018.

The rule specifies that Qualified Provider-Led Entities (QPLE) must develop the clinical guidelines that make up the appropriate use criteria, and CMS initially has approved the following 11 QPLEs :

Three of these (indicated with an *) have been developing radiology-specific clinical ordering criteria for many years. The criteria developed by these PLEs will be incorporated into the CDSMs ultimately installed in practice settings.  Other QPLEs may be added at the same time as the initial list of qualified CDSMs is published by CMS, no later than June 30, 2017.


It should come as no surprise the process used for reporting required usage of a CDSM via claims submission is not yet known, as the plans for such are currently under development at CMS and scheduled to be published in the 2018 Medicare Physician Fee Schedule (MPFS).  Once the methodology is defined, be sure to convey all information to your billing department whether they are in-house or an outside Revenue Cycle Manager (RCM).  If your medical billing partner is Medical Business Office (MBO), rest assured steps will be taken to ensure knowledge of how your system will indicate compliance with the requirements in order to avoid full payment denial.  As your MEDICAL BILLING SERVICE, and partner, MBO will be ready for this crucial change.

Hospital-based Radiology groups should have a voice in any planning process along side hospital administration for implementation of a system, if one does not already exist. The hospital must take charge in implementing the use of the CDSM by the ordering physicians. Fortunately, many times the CDSM is tied to the existing electronic order entry system utilized by the hospital. If this is the case, chances are good the entire system is integrated with the electronic health record (EHR) system and will subsequently assist the radiology group in its reporting responsibility (when filing claims and billing Medicare) of the consultation.

In the imaging center setting, aggressive research should already be in place with respect to the CDS systems available. The first stop for shopping should be the vendor that provides your RIS and/or PACS.  The vendor should be using AUC that are under development by one of the 11 PLEs listed above, and the system should be well along in the process of receiving CMS approval as a qualified CDSM.

And of course, lest you forget that regardless of the site of service, the ordering physician community will have to be educated on the need to comply with the ordering consultation requirements, and receive training on the new system.  Failure to educate will be detrimental to success. Education is a task all physicians in the group must embrace, because the cost of denied payments will add up quickly. Your designated Public Relations and/or Marketing crew should also become involved in the education.  As your MEDICAL BILLING SERVICE, MBO can easily illustrate how much Medicare revenue the practice receives from MRI, CT, PET, and other nuc med exams each year to understand what is at stake. The group should discuss how to handle exams ordered in a non-compliant fashion – how to provide constructive feedback to the ordering physician.  The sooner you implement, the better your compliance level will be by January 1st when denial of payment for noncompliance begins.

JANUARY 1, 2018 is right around the corner!