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:
So, if you’re on the referring side, use the MedicsCloud EHR and its qCDSM option either as a MedicsRCM client or through the MedicsCloud Suite as an in-house solution.
If you’re an imaging center, our qCDSM option can be a mechanism for your referrers if they need access to a qCDSM whether you’re using MedicsRIS as an in-house solution or our MedicsRCM service.
Donald Scott Featherman, MD
Head of CCA Group
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