Coding
Clinical Decision Support: Where Do We Stand Now?
Jeffrey A. Stone, MD, FACR
NASS Coding Committee Mayo Clinic Jacksonville, FL
As a result of the 2014 Congressional Protecting Access to Medicare Act (PAMA), the use of qualified Clinical Decision Support (CDS) tools approved by the Centers for Medicare and Medicaid (CMS) was implemented on January 1, 2020. These tools are to be used when ordering CT, MRI, and nuclear medicine (including Positron Emission Tomography-PET) radiological studies. The intent as stated by CMS was to enable health care providers to order the most appropriate test for individual patient care.
CMS further stipulated that data would be collected from the program to identify outliers who would then require preauthorization. This was implemented as an “education and operations testing period,” requiring ordering providers utilize appropriate use criteria (AUC) through a CMS-approved clinical decision support tool and indicate their National Provider Identification (NPI) number, the qualified CDS system used, and whether the service ordered would adhere to specified AUC criteria, would not adhere, or the AUC criteria were not applicable.
Therefore, an ordering provider requesting a lumbar spine MRI for chronic low back pain had to consult an approved CDS tool (built within the electronic health record or via the internet), enter the appropriate ICD-10 code(s), document which CDS tool was used in addition to their NPI on the request and ensure that the AUC result was available to the interpreting provider for an appropriate Healthcare Common Procedure Coding System (HCPCS) modifier to be attached to the claim.
Review of the initial program data indicated that only about 9-10% of ordering providers would be compliant and given the COVID-19 pandemic the education and operations testing period was extended through 2021. CMS also revised the process in December 2020, indicating that Medicare Administrative Contractors (MAC) would request pertinent supporting documentation from the treating/ordering practitioner. The result of this decision meant that any additional clinical information such as clarification as to why the imaging order did not adhere to AUC became the responsibility of the ordering professional.
The process for documentation proved cumbersome to practitioners, particularly given the ongoing COVID-19 public health emergency (PHE) and on July 7, 2022, CMS announced that the “penalty” phase would be delayed indefinitely until further notice beyond January 1, 2023 even if the PHE ended in 2022.
Looking Ahead
Jump ahead to 2024. CMS announced as part of the final rule that effective January 1, 2024, it was pausing efforts to implement the AUC program for reevaluation and rescinded AUC regulations. This resulted in the following changes:
- Providers and suppliers should no longer include AUC consultation information on claims. Claims submitted with this information would still be processed through the end of 2024.
- CMS will no longer qualify Provider Led Entities (PLE) or Clinical Decision Support Mechanisms (CDSM) used for the AUC process.
CMS did however encourage continued voluntary use of CDS tools for imaging guidance as it is estimated that utilization of AUC saved Medicare $700 million. It should also be noted that PAMA was not repealed, and the AUC component was indefinitely paused.
The application of CDS to spine-related ailments had been a focus of the AUC program throughout its testing period due to the widespread use of CT, MRI, and SPECT for diagnosis. Initial priority clinical areas of AUC designated by CMS included cervical/neck pain and low back pain. It is appropriate to assume that once the AUC requirement is reinitiated, these conditions will continue to be high priority areas. Efforts continue to develop new and improved mechanisms for AUC implementation that have the potential to ease the process for ordering providers. The potential use of artificial intelligence (AI) integrated into the electronic health record shows promise in both reviewing all available clinical data and automating the process of appropriate imaging modality selection, thus reducing the burden on the health care provider.
Author Disclosure
JA Stone: Other: North American Spine Society (Coding Committee member, Radiology Committee member); Research Support (Staff and/or materials): Benvenue Medical (Nonfinancial, Outside 24-Month Requirement); Speaking and/or Teaching Arrangements: North American Spine Society (Honorarium).