The Explanation: A new CMS initiative, the Appropriate Use Criteria Program (AUC) with a 1/22 deadline calls for physicians who refer Medicare patients for advanced imaging exams such as CTs, PETs, MRIs, and nuclear to have their ordering decisions be consulted for appropriateness with a qualified clinical decision support mechanism (qCDSM).
While not part of the initiative itself, ideally, the qCDSM would be accessed directly through the referring physician’s EHR which produces an appropriateness consultation for the patient’s imaging study based on any number of factors such as the patient’s clinical indications, complaint(s), etc.
The Penalty: It’s the imaging centers to which patients are referred for applicable advanced imaging that will have their claims denied if imaging is performed without having the proper appropriateness consultation information from the referrer’s side. Ultimately, referring physicians whose ordering patterns are considered outliers will be subject to prior authorization.
The Fallout: Once the deadline hits, providers will have a difficult – perhaps impossible – time finding imaging centers to accept Medicare patients if there’s no appropriateness consultation obtained with a qCDSM for the particular imaging order type. In addition, referring physicians could be subject to prior authorization in the future if ordering patterns are considered outliers.
The ADS Solution is actually two-fold:
- The MedicsCloud EHR - which is available through our MedicsCloud Suite, and almost always at no cost with MedicsRCM is enabled for decision support through Cranberry Peak’s qualified ezCDS mechanism. Referring physicians simply enter data as they normally would through the MedicsCloud EHR. Without having to exit the EHR, ezCDS will generate the appropriateness consultation information which the provider can make available to the imaging center.
- Our MedicsRIS (radiology) clients will be able to offer access to ezCDS through the MedicsRIS portal for referrers who don’t have their own qCDSM, helping to ensure themselves against denials.
So, if you’re on the referring side, use the MedicsCloud EHR and the ezCDS option either as a MedicsRCM client or through the MedicsCloud Suite as an in-house solution.
If you’re an imaging center, ezCDS can be an option for your referrers if they need access to a qCDSM whether you’re using MedicsRIS as an in-house solution or our MedicsRCM service.