Buried in the federal regulations describing Medicare’s Appropriate Use Criteria Program, which launches January 1, is a pertinent detail: The immediate financial burden of noncompliance with Medicare’s diagnostic imaging requirements will fall squarely on providers that furnish these tests.
Yes, that means radiology practices and hospital radiology departments, and not ordering providers.
For now, 2020 will be an educational and testing year for the program. Then, beginning Jan. 1, 2021, the Centers for Medicare and Medicaid Services will stop reimbursing radiologists and other providers who perform imaging for certain outpatient advanced diagnostic imaging claims if the ordering professional did not consult a qualified clinical decision support (CDS) mechanism, incorporating evidence-based appropriateness criteria.
The goal is to help ensure more appropriate imaging. Research suggests that 20 percent to 50 percent of imaging does not provide useful information that could change health outcomes, exposing patients to unnecessary radiation and contributing to high costs. CMS is betting that that program will lessen the need for Medicare to begin requiring prior authorizations on advanced imaging tests, which is the approach that commercial payers use.
For now, CDS requirements apply to advanced diagnostic imaging tests (such as CT scans, MRIs and PET scans). Appropriateness criteria need to be consulted for eight priority conditions, including low back pain and headaches, ordered in Medicare Part B outpatient settings, which includes emergency departments as well as physician offices and hospital outpatient departments.
Given the potential revenue losses, radiologists are recognizing that they need to help ordering providers adopt and adapt to using CDS for imaging orders. “A couple of years ago, we realized that we needed to be on top of this mandate because we could risk losing referrers if we’re not providing them an opportunity to use a CDS,” says Greg Nicola, MD, executive leadership of the Hackensack Radiology Group, a standalone imaging center serving Northern New Jersey.
In addition to providing access to imaging CDS, radiology providers are revamping relevant processes and workflows, engaging ordering physicians and ensuring CDS solutions do not add to physician burnout issues. “If you see this solely as an IT implementation, it’s going to fail,” says Keith Hentel, MD, executive vice chair of the department of radiology, Weill Cornell Medicine. “This is really a quality improvement project with a large IT component.”
The Technical Pieces
The University of Virginia (UVA) Health System has had imaging CDS in place for several years. The Charlottesville-based organization uses a CMS-qualified CDS system, CareSelect Imaging, which incorporates appropriate use criteria from the American College of Radiology and other medical societies. The CDS system is integrated with the organization’s Epic electronic health record.
However, many physicians at UVA still prefer to type a note justifying the need for imaging instead of selecting one of structured reasons provided on a pop-up screen. “We’ve kept CDS optional to be sensitive to the demands on our ordering providers,” says Christopher Gaskin, MD, vice chair of informatics. “Now that the hard requirements from CMS are upon us, we have to make CDS mandatory.”
Requiring the use of CDS will involve a relatively simple technical tweak, Gaskin says. Physicians won’t be able to order advanced diagnostic imaging in the EHR unless they select a structured entry. Free text entries will no longer be enough.
UVA will also give external referring providers, who typically fax orders, two options for accessing a qualified CDS mechanism. Ideally, these providers will switch to electronic orders by connecting to a web version of the health system’s EHR. Through this option, they will be able to access the CareSelect Imaging solution and select a structured entry for their order.
“We are looking to convert them from faxing orders to using an electronic portal to enter their orders, where they can access to the same decision support mechanism we’ve built for our UVA providers,” Gaskin says.
Alternatively, external providers who prefer faxing their orders can use a free online tool offered by UVA’s CDS vendor, National Decision Support Company, a Change Healthcare company. The standalone solution, CareSelect Imaging-Open Access, is a qualified CDS mechanism. After the provider enters the name of an imaging test and selects a medical indication for that test, the tool will give the provider information to submit with the faxed order.
With either approach, UVA will be able to document that the ordering provider met Medicare imaging requirements when seeking reimbursement from CMS. This documentation includes:
· A G code, which identifies the qualified CDS mechanism used
· An HCPCS Level II modifier, which indicates whether the ordering professional consulted appropriate use criteria, whether the order was deemed appropriate by the qualified CDS mechanism, or whether the professional met one of the Medicare exemptions for the requirement (e.g., the patient was experiencing a medical emergency).
Hackensack Radiology Group is anticipating that some referring physicians will purchase their own qualified CDS mechanism. For those that don’t, the New Jersey imaging center plans to provide a CDS mechanism via its physical referral portal. Currently, the radiology group is leaning toward a standalone qualified CDS solution offered by a radiology benefit management (RBM) company.
“For our imaging center, those RBM clinical support mechanisms may make the most sense because our referring clinicians are already using the same RBM portal to submit precertifications to commercial payers for imaging orders,” Nicola says.
Aiding Clinical Workflow
Weill Cornell Medicine has focused on integrating its CDS solution with the organization’s EHR to avoid adding to the physician burnout problem.
“Physicians have major demands on them and are spending incredible amounts of time within the electronic health record already,” Hentel says. “It’s our job to make the system as smooth as possible to mitigate burnout. The better integration you have, the better chance you have of making decision support interactions shorter.”
As an example, Hentel points to what happens when a physician orders a whole-body PET exam. The organization’s CDS solution scans the patient’s record for information that indicates the patient has or may have multiple myeloma or other diseases that can be appropriately diagnosed with this test. If the record shows the patient has multiple myeloma, the imaging order passes through, and the doctor is not prompted to answer any other questions.
This type of CDS-EHR integration requires a lot of work, Hentel says. “But it can pay dividends in terms of how quickly people get through the decision support interaction.”
Hackensack (N.J) Meridian Health, a 17-hospital system, uses a multidisciplinary approach to customize imaging CDS. “The radiologists and the ordering clinicians are part of the IT build to make sure that the screens are as relevant and streamlined as possible,” says Lauren Koniaris, MD, regional chief medical informatics officer, northern region.
These small groups of clinicians are charged with identifying the top medical indications for an imaging test. These common indicators are then listed first on the screen that pops up in the CDS mechanism. “You don’t want this overwhelmingly huge cluttered list,” Koniaris says. “You want a nice streamlined list and an option to dig deeper.”
Later this year, UVA will be piloting an artificial intelligence solution offered by its CDS vendor to simplify the ordering process. Physicians will be able to type free-text phrases or sentences about the patient’s condition in lieu of having to select a precise clinical indication from a pop-up screen. The AI solution will read the free text entry, propose a few possible structured clinical indications based on the notes, and the physician will be asked to confirm the correct indication.
“This way the radiologist gets the physician’s free text reason for the exam, which gives them a more complete story,” Gaskin says. “At the same time, the system can propose structured entries that will be compatible with offering decision support.”
At a yet-to-be-determined date in the future, CMS plans to call out ordering professionals who frequently do not comply with imaging CDS requirements. As a penalty, these professionals will need to seek prior authorizations for advanced diagnostic imaging orders.
“I don’t think CMS is going to judge you on each individual order,” Hentel says. “They just want to make sure there’s not a pattern [of noncompliance].”
Following a quality improvement approach, healthcare organizations are looking at how to provide relevant feedback on the appropriateness of imaging orders. “We want to be able to assess our compliance level as a health system and give feedback to providers and their clinical leaders about their performance,” Gaskin says.
UVH uses two data analytics solutions, one of which is home grown, to track how often imaging orders are compliant with appropriateness criteria and how likely each individual provider’s orders are to be appropriate given the patient’s medical condition. Gaskin and his team are currently holding conversations with clinical teams to determine how often and how best to share reports on provider compliance.
One of the biggest challenges to complying with the Medicare imaging requirements is getting autonomous physicians to embrace CDS, says Hentel. “Physicians don’t like being told what to do, and we certainly don’t like being told what to do by boxes sitting on desks,” he explains. “There’s no way that anybody’s going to convince me that a computerized decision support system knows overall how to take care of a patient better than a physician.”
To address this issue, Weill Cornell Medicine forms multidisciplinary teams of clinicians to review and develop the evidence-based appropriate criteria used in its imaging CDS. The teams begin by reviewing appropriateness criteria developed by other qualified provider-led entities. If the team believes the criteria can be improved on, they develop new criteria. The medical center’s physicians organization is recognized as a qualified provider-led entity by CMS.
“We wanted to ensure that the advice that we’re giving physicians is consistent with what we believe to be best practice,” Hentel says.
An honest dialogue about the effectiveness of CDS in improving patient care and lowering costs may also help engage ordering physicians. Research suggests that the appropriateness of imaging studies tends to increase with the use of CDS, meaning patients are more likely to get the right test at the right time. But it is unclear if total volumes of imaging tests will decline.
When talking with clinicians about the Medicare imaging requirements, Nicola stresses that CDS is just one tool in the performance improvement toolbox. “There’s no magic bullet for increasing value in patient care,” he says. “I think, as a physician community, it would be naïve to think that any one electronic tool in isolation could improve value. However, the CDS tool, mixed with an engaged team of ordering and furnishing providers who want to use it in an active fashion and learn from it, could be very valuable. But you need to have that [quality improvement] mindset.”