7 Things You Need to Know Now About Appropriate Use and Clinical Decision Support

For physicians who treat Medicare patients, everything changes next New Year’s Day. That’s when real consequences begin to befall those who order advanced imaging—CT, MRI or PET scans—without first consulting appropriate use criteria (AUC). They’ll need to show they did so by using a CMS-qualified clinical decision support mechanism (qCDSM).

The ordering physician is not required to go along with the CDSM’s recommendations. He or she just needs to show that a mechanism was consulted. Still, the development represents a big and binding step in the evolution of medical reimbursement in the U.S.

This didn’t come from out of the blue. Medicare’s AUC program is a linchpin in the Protecting Access to Medicare Act (PAMA) of 2014. A voluntary reporting period during which early adopters can make a habit of using their qCDSM has been underway since July 2018 and will run through this year.

However, close CMS watchers as well as attentive healthcare providers can see the writing on the proverbial wall: The future arrives gradually, then suddenly.

One of the close CMS watchers saying as much is Serena Sardo, a radiology coding compliance supervisor with 50-state, 500-radiologist vRad. In a recent phone interview, Sardo outlined seven important yet easily overlooked points about AUC.

1. If you receive payments through CMS’s Hospital Outpatient Prospective Payment System (HOPPS), you will be impacted by the agency’s AUC program. This goes for hospital outpatient service lines, emergency departments, ambulatory surgical centers, physician offices, provider-led outpatient centers and certain critical- access hospitals.

Which is to say the program has an eye on pretty much every clinician who orders advanced imaging in every setting other than inpatient, Sardo suggests.

“If you’re looking for exemptions and hardships, they’ll apply only under certain strict circumstances—if the patient is critical and is being seen in the ER, for example,” Sardo says. “In those cases the imaging exam would be exempted from having to report a consultation with a qCDSM. And even there, the ordering physician needs to show a true emergency with life-threatening conditions.”

2. CMS’s official AUC timeline is helpful, but it also may be misleading. The agency has it that 2020 is to be a year of “educational and operations” testing, meaning there’ll be no immediate penalty for lack of compliance. But it’s likely CMS won’t wait to begin compiling data on those who seem to be dragging their feet on AUC acceptance as verified by qCDSM utilization.

Then, in future years—certainly by 2024 but possibly as soon as 2021—many of these slow adopters could be forced to obtain preauthorization for every advanced imaging exam they wish to order. “You want to catch any issues during the testing period,” Sardo says. “It’s best to start pinpointing your referrers who are not engaged with this—and start working with them— before the denials start coming.”

3. Unlike CMS incentive programs, AUC doesn’t offer nice bonuses or threaten percentage penalties. Instead, it’s a straight thumbs-up or -down. Fail to order with a qCDSM, and you may not bill for the exam at all. Do so repeatedly, and you might find yourself on the “Preauthorization Required”  list.

“Usually we haven’t seen such a drastic hard line on CMS reimbursement,” Sardo observes. “I think CMS has been taking this very seriously. They really want to reduce costs, and this is one way they’re going to do it. The denial process and the loss of revenue it brings are extremely concerning for everyone in radiology right now.”

On the bright side, many providers have been using a CDSM to report improvement activity, and thus boost their quality scores, through CMS’s Merit-based Incentive Payment System. MIPS began heavily weighting such activities in January 2018, so these providers are well familiar with the CDSM process. 

Those who haven’t gotten their bearings on AUC via MIPS are courting trouble if they wait till 2020’s “educational and operations” period to start, Sardo says.


4. Just because a given case seems like a true emergency doesn’t mean it is one (in CMS’s eyes, that is). In its final rule on AUC, CMS states that neither the rendering physician nor the reading radiologist can make the call on what constitutes a true emergency. “The only person who can attest to it is the ordering physician,” Sardo says. “The orderer does this on the order form, and there is no other way to attest to that exemption.”

Sardo adds that vRad knows this narrow path of exemptions for emergent imaging will vex many ordering providers early on. “We’re trying to do a lot of smart integrations with our order-management system to make this as easy as possible for ER doctors,” she  says. “We want to offer as much education as possible on what will be considered an exempt case.”

5. Reading radiologists will feel the heat even though they can only do so much fire prevention. Indeed, they’ll receive payment denials if they interpret advanced imaging exams that come through without AUC data via a qCDSM.

“At vRad we’ve done the financial analysis on this, and the impact runs into the millions of dollars in potentially lost revenue due to non-compliance with AUC,” Sardo says. “Frankly, this is one of the reasons we’re working to get the word out.” 

At the same time, vRad is well aware that its own success is closely tied to that of its clients and their related stakeholders. “We’re here to support not only the referrers but also the facilities that are going through this,” Sardo says. “A lot of our clients are on both sides of that coin.”

She adds that vRad works with hospitals whose staff ER doctors will be challenged to engage the qCDSMs.  “They’re also the people who are sending us images to interpret,” she says, “and they too are going to be on the hook for that revenue loss if they’re slow adopters.”

6. Given the gathering push for transparency, it’s not unreasonable to think CMS will, at some point, publish a list of AUC stragglers to guide healthcare consumers. The agency hasn’t hinted that it’s mulling such a move. But these are times of potential sweeping change in U.S. healthcare: Medicare for All, anyone? And, as Sardo points out, having to get preauthorization would be a major negative in its own right—especially for ER doctors and doctors with high volumes who are constantly ordering out.

“Even for primary care physicians, being required to get preauthorizations for all high-modality imaging exams will make life hard,” she says. “Will your patients want to stay with you? If they need to get preauthorization with you but not with another doctor down the street, they may leave you.”

There are a lot of unknowns and ramifications around the possibility of preauthorization and what that requirement would mean for AUC outliers, she underscores.

“CMS hasn’t fleshed out those ramifications yet, probably because they’re very focused on how this is going to work day to day,” she adds. “But we will definitely see a ripple effect on doctors who need preauthorization for failing to integrate a CDSM into their workflows. The added work could affect their patients, their radiologists and other people they deal with every day.”

7. There’s no one-size-fits-all selection on the qCDSM market. “Before you pick a CDSM, you really should do a financial analysis of the impact,” Sardo advises. “Depending on your financial stake in the decision, you may want to look at one of the more robust qCDSMs, meaning the ones that have a lot of bells and whistles.”

For many, an obvious candidate to consider will be the American College of Radiology’s CareSelect. But it does have competition, some of which is formidable and worth a look, suggests Sardo.

Sardo closes the conversation on an invitation.

“If anyone out there wants to start CDSM testing before 2020, we want to work with them as a testing partner,” she says. “We’re very actively trying to engage as many clients as possible to be prepared so nobody has to react to the AUC changes with an end-of-the-year scramble as 2020 closes in. We want to keep our clients—and ourselves—ahead of the curve.”