Here are my thoughts on the CMS's 2019 MPFS Final Rule's prepublication comments concerning the implementation of Clinical Decision Support. Be sure to read the last paragraph if your practice files claims or has a billing company//office filing them for you.
Rule applies to IDTFs: CMS added IDTF's to the types of facilities that are subject to CDS reporting requirements.
[MB: In my opinion, this is merely a technical correction that simply codifies what was intended from the beginning.]
Who is allowed to perform the consultation: CMS clarified who must perform the consult. In the final rule CMS explicitly allows auxiliary personnel incident to the ordering provider to perform the CDS consultation. CMS stated: "we believe it is important that the individual who uses the CDSM is working under the ordering professional, and that the individual is available to the ordering professional to discuss the results of the consultation and any responsive adjustments to planned orders."
[MB: If the ordering provider delegates the AUC consultation, the person to whom the task is delegated must be working "under the direction" of the ordering professional and should have reasonable access to discuss the AUC consult outcome with the physician.]
Allowing Imaging Facilities to Consult on Behalf of the Ordering provider: Some commenters suggested that the furnishing provider (e.g., hospital, imaging center, or radiologist) be allowed to "occasionally consult" the AUC using a CDSM on behalf of the ordering provider.
CMS's response was clear. They wrote that "While a furnishing professional may consult AUC as they wish for other purposes, such a consultation would not suffice for purposes of the AUC consultation required under this program. The AUC consultation must be performed by the ordering professional."
[MB: This was a clear and unequivocal statement by CMS. Delegation of the AUC consult by the ordering provider to the furnishing provider is prohibited for purposes of this program.]
Potential for Conflicting Data – CMS will not compare TC and PC Consult Data: Some commenters noted that because both the facility and interpreting provider are each independently submitting the AUC consult outcomes for the same test there is a potential for them to submit inaccurate or conflicting information. CMS acknowledges this potential and responded as follows:
"We recognize that . . . the TC or facility portion of an applicable imaging service is frequently furnished and billed by a different entity than the PC portion of the service. We do not currently do any matching or comparison of separate claims for the PC and TC or facility portion of an advanced diagnostic imaging service. Rather, we process these separate claims individually, and have no immediate plans to begin doing otherwise for purposes of the AUC program. We hope to learn more about the implementation of this program, including issues such as these commenters have raised, during the educational and operations testing period."
[MB: This is an interesting section. CMS acknowledges the potential for the facility reporting the TC and the provider reporting the PC to report different AUC outcomes. In such situations, one of the submitted data sets would have to be an error. However, CMS indicates they have no immediate plans to compare the furnishing TC and PC consult outcomes.]
Multi-exam Claims: Several commenters pointed out the difficulty multi-exam studies present. Many felt it may require filing exams that could normally be filed on the same claim to be filed separately. Commenters also pointed out that, while the furnishing providers' billing systems are capable of reporting G-codes and modifiers, there is an issue how billing systems place codes on the claim which will result in a different order. There was a concern this would disassociate the AUC consult outcome coding from the exam it represents when more than one imaging service appears on the claim.
Here is CMS's response:
"We agree with commenters that the issue of claims processing system resorting of claims information is problematic. When multiple imaging services are reported on a single claim, it will not be possible to pair the G-code describing which CDSM was consulted with the imaging service for which it was consulted. While we could require the furnishing professional to split the claim, we are not committing to that solution at this point but will explore that option as we move forward with implementation. Another possible solution, though still imperfect, could be to list the G-code on a line and place the modifiers describing AUC adherence on the line with the CPT code describing the imaging service. This model could work when the same ordering professional has ordered all of the furnished imaging services on the claim, and if we presume that an ordering professional will consistently use only one qualified CDSM."
[MB: This is an important section as it will have a positive implication for filing claims. While the procedure and AUC consult outcome must be on the same claim, the order of the information is immaterial. This is particularly important when multiple studies requiring AUC consultation are performed (e.g., CT Chest and CT Abdomen/Pelvis). For technical reasons, it would have been difficult to ensure the procedure codes and their related consultation identifiers are placed in some sort of order. In the end, furnishing providers may put the exam procedure and AUC consult information in any order on their claims.
Duty by CDSM's to Provide G-code and Outcome Modifiers: Many people requested that the mechanisms be required to provide their assigned G-code and the outcome modifier to the furnishing providers, instead of just giving them the Mechanism name and whether or not the consult adhered, did not adhere, or the criteria did not apply. CMS acknowledged this concern and responded as follows:
". . . we agree with commenters that CDSMs should include the G-codes and modifiers in their certification or documentation. We would like to see CDSMs begin to do this as the specific G-codes and modifiers become available. And as the commenters noted, this would seem to be a simple thing for CDSMs to do. If we do not see CDSMs making such adjustments to their certification or documentation, we will consider imposing a requirement in regulation."
Emergency Medical Condition:
PAMA provides for an exception to the AUC consultation if they meet the definition for an emergency as defined in Section 1867(e) of the Social Security. The definition of an emergency is as follows:
- a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in-
- placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy,
- serious impairment to bodily functions, or
- serious dysfunction of any bodily organ or part; or
- with respect to a pregnant woman who is having contractions-
- that there is inadequate time to effect a safe transfer to another hospital before delivery, or
- that transfer may pose a threat to the health or safety of the woman or the unborn child.
Put simply, not every exam ordered through an ER department will meet this definition. Those that don't meet the definition of being an emergency will require the ordering provider to perform a AUC consultation and provide the results to the furnishing facility and providers.
CMS confirmed its commitment to requiring ordering providers to perform an AUC consult for non-emergent exams (even in the ER) when it wrote ". . . we will not amend our regulation in response to these comments." However, CMS clarified its position by writing: ". . . we agree that exceptions granted for an individual with an emergency medical condition include instances where an emergency medical condition is suspected, but not yet confirmed. This may include, for example, instances of severe pain or severe allergic reactions. In these instances, the exception is applicable even if it is determined later that the patient did not in fact have an emergency medical condition."
[MB: In my opinion, determining what constitutes an "emergency" will be a one of the largest sources of confusion and discussion within hospitals and their ER departments.]
Hardship Exception:
CMS is finalizing its hardship categories as:
- insufficient internet access,
- EHR or CDSM vendor issues, and
- extreme and uncontrollable circumstances.
Ordering professionals are allowed to simply "self-attest" they have a hardship at the time of ordering and the furnishing providers would communicate this on their claims by appending a HCPCS modifier identifying the ordering professional's self-attested significant hardship category.
[MB: This is good news for both ordering and furnishing providers. It is worth noting that this places the compliance burden for determining hardship squarely on the shoulders of the ordering professional. The furnishing providers will simply report the hardship category given them by the ordering provider on their claims. Since no consult was performed there is no CDSM G-code to report.]
---------------------------------------------------------------
Summary: We know a lot more today than we did two weeks ago. The program is on track for a January 1, 2020 start date. Denials due to inappropriate or missing furnishing provider claim information will begin on January 1, 2021.
Everyone should know that there is much work to do to operationalize the process, primarily in terms of redesigning our data export and imports and reconfiguring our billing systems, to obtain and correctly pair the procedure with its related AUC consult outcome codes and modifiers. The scale of what has to happen in the next 12-18 months is huge: Every hospital must revise their data export and every radiology group and their billing systems and/or billing companies must redesign their data import processes to pair the procedure information with its related AUC consult information.
IHE's CDS-OAT profile established the framework for capturing and sharing this information between and among the various medical record systems involved. Now it is time to focus on redesigning our data exports and imports to get this information on the claim. Don't wait too long to begin working on your solution. We are nearing the end. One last push and we can get there!
------------------------------
Michael Bohl FRBMA
Radiology Group, PC, SC
Davenport IA
------------------------------