understanding appropriate use criteria for cy 2020 › sites › corporate › files › radnet ›...

Understanding Appropriate Use Criteria for CY 2020

Ordering Professionals

Current CMS Requirements & Definitions

WHEN? “Educational and operations testing period” starting on January 1, 2020 Participation is encouraged; no claims will be denied for missing or inaccurate AUC

information

WHAT? Qualified CDS mechanism (QCDSM) consulted AUC adherence score NPI of ordering clinician

HOW? G-code for QCDSM consulted Modifiers indicate whether the order:

• Adhered • Did not adhere • Was not applicable to AUC • Is eligible for an exception

THE NEW AUC RULE


APPLICABLE IMAGING SERVICES? MRI CT NM PET

APPLICABLE SETTINGS? Physician offices/imaging centers Hospital outpatient departments

(including ED) Ambulatory surgical centers Independent diagnostic testing facilities

APPLICABLE PAYMENT SYSTEMS? Medicare Physician Fee Schedule Hospital Outpatient Prospective Payment System ASC payment system

EXCEPTIONS?

Inpatient (Medicare Part A)

Life-threatening conditions

Hardships (lack of Internet, EHR failure, disasters)

AUC? Evidence-based guidelines for imaging

appropriateness

THE NEW AUC RULE


FURNISHING PROFESSIONAL? Us (radiologist, imaging center, radiology

department) ORDERING PROFESSSIONAL? You (physician or non-physician) QUALIFIED CLINICAL SUPPORT MECHANISM? CMS-approved electronic tool for using

AUC Scores based on appropriateness G-CODES? CMS code for “Temporary Procedures &

Professional Services”

MODIFIERS? Two-digit at end of code APPROPRIATENESS SCORE? Higher the score, the more appropriate

the test Colors indicate appropriateness

THE NEW AUC RULE

CMS QCDSMs and G-Codes

CDS – Clinical Decision Support AUC – Appropriate Use Criteria

Source: CMS MLN Matters 11268 dated July 26, 2019

THE NEW CMS RULE

Offers free web-based CDS tool

QCDSM G-code WebsiteApplied Pathways CURION™ Platform G1000 https://appliedpathways.com/eviCore healthcare's Clinical Decision

Support MechanismG1001

https://www.evicore.com/ (CDSM information available in November)

MedCurrent OrderWiseTM G1002 https://www.medcurrent.com/

Medicalis Clinical Decision Support Mechanism

G1003https://www.siemens-healthineers.com/digital-health-

solutions/digital-solutions-overview/service-line-managment-solutions/imaging-service-line/medicalis/clinical-decision-support

National Decision Support Company CareSelect™*

G1004 https://nationaldecisionsupport.com/pama/

National Imaging Associates RadMD G1005 https://www1.radmd.com/radmd-home.aspxTest Appropriate CDSM* G1006 http://www.testappropriate.com/#home

AIM Specialty Health ProviderPortal®* G1007https://aimspecialtyhealth.com/solutions/health-systems-and-

providers/aim-inform/Cranberry Peak ezCDS G1008 http://www.cranberrypeak.com/

Sage Health Management Solutions Inc. RadWise®

G1009 https://www.sagehms.com/radwise

Stanson Health's Stanson CDS G1010 https://stansonhealth.com/pama/

Qualified Tool Not Otherwise Specified** G1011 N/A

** Other CMS QCDSMs: AgileMD’s Clinical Decision Support Mechanism, Cerner CDS mechanism, EvidenceCare’s Imaging Advisor, Evinance Decision Support, Flying Aces Speed of Care Decision Support, HealthHelp’s Clinical Decision Support Mechanism, Infinx CDSM, Inveni-QA's Semantic Answers in Medicine™, LogicNets' Decision Engines, New Century Health's Care Pro, Reliant Medical Group CDSM (Source: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/CDSM.html)

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/CDSM.htmlhttps://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/CDSM.htmlhttps://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/CDSM.htmlhttps://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/CDSM.htmlhttps://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/CDSM.htmlhttps://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/CDSM.htmlhttps://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/CDSM.htmlhttps://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/CDSM.htmlhttps://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/CDSM.htmlhttps://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/CDSM.htmlhttps://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/CDSM.htmlhttps://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/CDSM.htmlhttps://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/CDSM.htmlhttps://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/CDSM.htmlhttps://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/CDSM.htmlhttps://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/CDSM.htmlhttps://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/CDSM.htmlSheet1

QCDSMG-codeWebsite

Applied Pathways CURION™ Platform G1000https://appliedpathways.com/

eviCore healthcare's Clinical Decision Support MechanismG1001 https://www.evicore.com/ (CDSM information available in November)

MedCurrent OrderWiseTM G1002https://www.medcurrent.com/

Medicalis Clinical Decision Support MechanismG1003https://www.siemens-healthineers.com/digital-health-solutions/digital-solutions-overview/service-line-managment-solutions/imaging-service-line/medicalis/clinical-decision-support

National Decision Support Company CareSelect™*G1004 https://nationaldecisionsupport.com/pama/

National Imaging Associates RadMDG1005https://www1.radmd.com/radmd-home.aspx

Test Appropriate CDSM*G1006http://www.testappropriate.com/#home

AIM Specialty Health ProviderPortal®*G1007https://aimspecialtyhealth.com/solutions/health-systems-and-providers/aim-inform/

Cranberry Peak ezCDS G1008http://www.cranberrypeak.com/

Sage Health Management Solutions Inc. RadWise®G1009https://www.sagehms.com/radwise

Stanson Health's Stanson CDSG1010https://stansonhealth.com/pama/

Qualified Tool Not Otherwise Specified**G1011 N/A

Sheet2

Qualified Clinical Decision Support Mechanisms as of June 2019G-Code

AgileMD’s Clinical Decision Support MechanismG1011

Applied Pathways CURION™ PlatformG1000

eviCore healthcare's Clinical Decision Support MechanismG1001

MedCurrent OrderWiseTM G1002

Medicalis Clinical Decision Support MechanismG1003

National Decision Support Company CareSelect™*G1004

National Imaging Associates RadMDG1005

Test Appropriate CDSM*G1006

AIM Specialty Health ProviderPortal®*G1007

Cranberry Peak ezCDS G1008

Sage Health Management Solutions Inc. RadWise®G1009

Stanson Health's Stanson CDSG1010

EvidenceCare’s Imaging AdvisorG1011

Inveni-QA's Semantic Answers in Medicine™G1011

Reliant Medical Group CDSMG1011

Clinical Decision Support Mechanisms with Preliminary Qualification as of June 2019

Cerner CDS mechanismG1011

Evinance Decision SupportG1011

Flying Aces Speed of Care Decision SupportG1011

HealthHelp’s Clinical Decision Support MechanismG1011

Infinx CDSMG1011

LogicNets' Decision EnginesG1011

New Century Health's CareProG1011

Sheet3

CMS AUC Modifiers

THE NEW CMS RULE

Type Modifier Description Emergency Medical Condition

MA Ordering professional is not required to consult a clinical decision support mechanism due to service being rendered to a patient with a suspected or confirmed emergency medical condition

Hardship Exception

MB Ordering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of insufficient internet access

Hardship Exception

MC Ordering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of electronic health record or clinical decision support mechanism vendor issues

Hardship Exception

MD Ordering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of extreme and uncontrollable circumstances

AUC Adherence ME The order for this service adheres to the appropriate use criteria in the clinical decision support mechanism consulted by the ordering professional

AUC Adherence MF The order for this service does not adhere to the appropriate use criteria in the qualified clinical decision support mechanism consulted by the ordering professional

AUC Adherence MG The order for this service does not have appropriate use criteria in the clinical decision support mechanism consulted by the ordering professional

Missing AUC Consultation Information

MH Unknown if ordering professional consulted a clinical decision support mechanism for this service, related information was not provided to the furnishing professional or provider

QQ Ordering professional consulted a qualified clinical decision support mechanism for this service and the related data was provided to the furnishing professional (effective date: 7/1/18)

Source: CMS MLN Matters 11268 dated July 26, 2019

Accessing a QCDSM

1. CMS approved QCDSMs 2. Free web application (e.g., CareSelect, AIM Specialty Health, Test Appropriate CDSM) 3. CDS integrated into EHR

4. RadNet’s Provider Portal (coming later in 2020)

How AUC Works

Performing AUC Consultation

Step 1: Enter required information • Patient age • Patient sex • Procedure/service ordered • Clinical indication(s)/reason(s) for exam

Step 2: Appropriateness score • Procedure/service ordered • Alternatives

Step 3: Select procedure Step 4: AUC confirmation with consultation information Step 5: AUC confirmation delivery means Step 6: Forward consultation information (G-code + modifier) to RadNet with order .

How AUC Works

Systems may vary

Performing AUC Consultation How AUC Works

CareSelect Open Access Portal (registration required) -- https://openaccess.careselect.org Clinical vignette: Order a CT head/brain for a 75yo male with headache

Coming by end of 2019

What You Need To Do

RadNet can accommodate AUC consultation information in multiple ways:

How AUC Works

Fax EHR

Provider Portal

Phone

(Coming later in 2020)

AUC is better patient care

AUC is much better—in terms of efficiency, cost, and patient care—than reliance on traditional prior authorization AUC ensures quality—right exam for

the patient, at the right time, and the right cost AUC is more cost-effective and less

burdensome—a greater value—for patients, clinicians, and payors

Why AUC?

AUC Resources

CMS: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/OandE Professional Societies RadNet

• www.RadNet.com/AUC • [email protected] • Educational materials

• “What to Know” “FAQs”

AUC Help

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/OandEhttps://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/OandEhttp://www.radnet.com/AUChttp://www.radnet.com/AUCmailto:[email protected]

Key Takeaways: • “Educational and operations testing period” goes into effect on

January 1, 2020 • Participation is encouraged; no claims will be denied for missing

or inaccurate AUC information • G-codes + modifiers report required AUC consultation • Easy; instantaneous feedback • Better patient care; no loss of autonomy

Conclusion


Question & Answer Session


Thank you!

Slide Number 1Current CMS Requirements & DefinitionsCurrent CMS Requirements & DefinitionsCurrent CMS Requirements & DefinitionsCMS QCDSMs and G-CodesCMS AUC ModifiersAccessing a QCDSMPerforming AUC ConsultationPerforming AUC ConsultationWhat You Need To DoAUC is better patient care�AUC ResourcesKey Takeaways:�Slide Number 14Slide Number 15

understanding appropriate use criteria for cy 2020 › sites › corporate › files › radnet ›...

Documents