The Explanation: It’s a CMS initiative which is expected to become a reality at some point, although we’re ready for it right now!
Officially, it’s known as the Appropriate Use Criteria Program (AUC). It will affect physicians who refer Medicare/Medicaid patients for advanced imaging exams such as CTs, PETs, MRIs, and nuclear, by requiring them to have their ordering decisions be approved by a qualified clinical decision support mechanism (qCDSM). So yes, providers will need to have their imaging orders approved by a qCDSM.
The qCDSM would take into account the patient’s history, age, complaints, etc., and “ping” that data off the qCDSM to see if the MRI, for example, is approved. If an approval is returned in the form of a G code, the Medicare/Medicaid patient is cleared for the study and that G code is transmitted with the order to the imaging center.
The Penalty: It’s not on the referrer, it’s on the imaging center! The imaging center will have any claims denied for patients who were supposed to have G codes but didn’t.
The Fallout: Once the deadline hits, providers will have a difficult – perhaps impossible – time finding imaging centers to accept Medicare/Medicaid patients if there’s no appropriateness consultation (G Code) obtained from a qCDSM for the imaging order. 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 - Referring physicians simply enter encounter data as they normally would. Without having to exit the EHR, our qCDSM option will generate the G Code which the provider makes available as part of the order to the imaging center. Conversely, a G Code may not be issued which will be a problem if the provider is convinced the particular study is needed. Those patients may have to self-pay the imaging center for the study.
- Our MedicsRIS (radiology) clients will be able to offer access to our qCDSM option through the MedicsRIS portal for referrers who don’t have their own qCDSM, helping to ensure themselves against denials.
So, we’ll have you covered whether you’re on the referring or imaging side!
Contact us for more about our qCDSM solution, and be ready in advance for the AUC initiative.