Clinical Decision Support

These are physician-developed guidelines clinically oriented to guide decision making about when a medical procedure, service or test would be appropriate or not, and which exam or procedure is most appropriate for the patient’s condition, illness or injury.

AUC are created and maintained by professional societies and other entities.

The ACR Appropriateness Criteria®, the ACR AUC guidance, are multispecialty, physician-developed, evidence-based and transparent. They are considered the most comprehensive for imaging.

In 2023, the ACR AUC provided 233 diagnostic imaging and interventional radiology topics with over 1,100 variants and, for Diagnostic Imaging topics, there were 3,000 clinical scenarios.

The guidelines are developed and reviewed annually by expert panels in diagnostic imaging and interventional radiology. Each panel includes leaders in radiology and other specialties.

In 2014, Congress passed the Protecting Access to Medicare Act (PAMA) to ensure millions of seniors could maintain access to critical health services.

PAMA requires an AUC consult to be performed via a CMS-qualified clinical decision support mechanism (qCDSM) when ordering advanced diagnostic imaging for Medicare patients.

The process reduces and/or eliminates inappropriate advanced imaging services from being performed, thus saving Medicare money. If the PAMA AUC program is implemented, CMS estimates a savings of potentially $700 million annually to the Medicare program. According to an analysis by The Moran Company (TMC), the savings to beneficiary cost sharing is estimated to be roughly $1.4 billion over ten years.

The PAMA AUC program has not been repealed, but was paused by Congress on January 1, 2024, while Congress considers legislative improvements to the program specifically around the real-time claims processing aspect of the statute. ACR and CMS strongly urge providers that have already implemented CDS programs to continue to use them during this pause.

The real-time claims processing requirement can easily be addressed by a simple statutory change to the law.

The PAMA AUC law has not been repealed, only paused. CMS encourages the continued voluntary use of CDS tools. Providers will be better prepared to meet the AUC mandate when a legislative fix is implemented, and the program moves forward.

Regardless of the CMS AUC mandate, this CDS system has numerous benefits for providers and patients.

While the PAMA statute only applies to imaging performed in physician offices and outpatient settings, hospital systems can use CDS for inpatient care as well, leading to more efficient care for all hospital patients.

Compared to alternatives such as prior authorization, which imposes huge administrative burdens on physician practices and shifts costs onto physicians, AUC systems optimize patient care by guiding providers’ determinations of a patient’s advanced imaging needs. In an era where workforce shortages demand solutions, CDS empowers providers to order the most appropriate exams and helps prevent critical findings from being delayed.

• Imaging facilities/practices/departments will not have to change their reporting lexicon or approach. Care Select Imaging, which is the qCDSM containing the ACR Appropriateness Criteria diagnostic imaging topics, and likely other CDSM vendors as well, can work with imaging providers to incorporate current lexicon into the system workflow.
• CDS can be done even if referring and rendering providers do not share a common EHR/EMR system. Care Select Imaging contains the ACR Select™ module, which contains the ACR Appropriateness Criteria diagnostic imaging topics. Perhaps other CDSM vendors can serve this function, documenting AUC consultation and providing necessary “identifier” codes to include in Medicare imaging claims.
• Imaging providers will not be competitively disadvantaged by this federal requirement:
• No rendering provider can receive Medicare payment for an ADIS if the referring provider does not attach an HCPCS/G-codes and modifiers to the referral.
• All radiology providers may refuse Medicare referrals without this documentation, with few exceptions as outlined above.
• Imaging providers cannot perform AUC administrative duties for referrers (as with prior authorization).
• Ordering providers cannot shift the AUC requirement to radiologists.
• There is no facility “exempt” from PAMA requirements (other than those exceptions outlined above) to which providers can shift this Medicare imaging.
• These factors should quickly result in integration of CDS in referring practices.
• The minimal cost to imaging providers to implement AUC/CDS is far less than losses due to Medicare (and subsequent private payer) reimbursement cuts – and/or radiology benefits management (RBM) denials to follow if AUC/CDS program fails.
• CDS does not reduce necessary revenue. It helps facilities and departments gain market share by strengthening their ability to accommodate new patients and demonstrates quality to referring providers.
• This change is not sudden. CMS has granted physicians more than eight years to prepare for implementation (from April 1, 2014, when PAMA became law) and is implementing AUC/CDS via the rulemaking process, asking for provider input at every point.
• CDS can be, and is being, efficiently put in place nationwide. AUC-CDSMs have successfully adopted EHR integration in over 500 health systems and 3,000 acute care facilities in all 50 states.
• CDS can ultimately reduce administrative burden on imaging providers. It provides data to help demonstrate utilization management and negotiate an end to preauthorization.
• CDS helps providers engage patients in their care. Providers can use CDS to show them why a certain exam may be (un)necessary. This leads to better shared decision making.
• All AUC in a given qCDSM need not be consulted. No imaging provider would be penalized in any way for choosing a qCDSM that contains more AUC than another.
• Providers need only consult the AUC that applies to the individual advanced imaging exam to be ordered.
• In many cases, particularly when the qCDSM does not contain AUC, consultation can be automatic.
• A qCDSM is required to have reasonable coverage of Priority Clinical Areas (PCA). There is no defined maximum.
• Having access to comprehensive AUC enables organizations to manage utilization across all services, which can help eliminate the overhead of prior authorization across all payers.
• As the PCA will expand, comprehensive coverage can help keep practices ahead of future rulemaking.

Both technical and professional component claims will ultimately require evidence of consultation to be payable. Practice setting will influence how practices work with referring providers and adapt workflows. Below are care-setting-specific tips gathered through experience to date.

• Hospital Based Practice. Ensure that affiliated institutions have integrated qCDSM into their EHR and that the consultation information flows to your revenue cycle applications for professional and technical billing. A good way to measure this is to ensure that the structured indication selected by the ordering provider is available in your interpretation workflow.
• Ambulatory Imaging Practice
• Educate referrers on availability of no fee access points, including via several ambulatory EMR applications.
• Ensure workflows and integrations to receive electronic orders include consultation information (if available).
• Become familiar with AUC consultation process and enable referring providers.
• In some cases, your practice may only receive a unique consultation identifier generated by the qCDSM. You may need to access or integrate with the qCDSM to retrieve claims data.
• Ideally the structured indication selected by the ordering provider is available in your interpretation workflow.
• Sign up for/with the qCDSM to become familiar with the process.
• Private Practice
• Ensure your professional billings include the necessary consultation data. This will require that your billing company work to include the consultation data into their processes.
• Ensure that the systems interacted with include the structured indication selected by the ordering provider.
• Sign up for/with the qCDSM to become familiar with the process.

When speaking to your IT, medical and professional staff:

• Explain why you are doing this — legislative requirement and quality improvements — via:
• Grand rounds/staff meetings
• Network emails
• Newsletters

Ensure that your IT/informatics team is incorporating AUC into your electronic medical record (EMR) and image ordering and fulfillment systems.

• Meet with various stakeholders.
• Obtain buy-in from administration.
• Obtain buy-in from ordering practitioners.
• Obtain buy-in from information systems (IS) and information technology (IT).

Educate relevant staff on how to use the AUC/CDS system you choose — your qCDSM vendor can help.

• Hold weekly conference calls with vendor, IS/IT and ordering provider leaders.
• Create an instruction video and set up mandatory viewing prior to turning on CDS system.
• Distribute a PDF instruction manual and/or newsletters.

The statute requires the identification of outlier ordering professionals. Once CMS has collected two years of ordering data, providers identified as ordering outliers will be subject to a prior authorization requirement. The list of priority clinical areas will serve as the basis for identifying outlier ordering professionals.

The final list of priority clinical areas includes the following clinical conditions:

• Coronary artery disease (suspected or diagnosed).
• Suspected pulmonary embolism.
• Headache (traumatic and non-traumatic).
• Hip pain.
• Lower back pain.
• Shoulder pain (to include suspected rotator cuff injury).
• Cancer of the lung (primary or metastatic, suspected or diagnosed).
• Cervical or neck pain.

Future MPFS rules are expected to provide further clarity behind the concept of “prior authorization.”

Consulting and reporting requirements are not required for orders for applicable imaging services made by ordering professionals under the following circumstances:

• Emergency services when provided to individuals with emergency medical conditions as defined in section 1867(e)(1) of the Act.
• For an inpatient and for which payment is made under Medicare Part A.
• Ordering professionals who are granted a significant hardship exception to the Medicare EHR Incentive Program payment adjustment for that year.
• The U.S. Department of Health and Human Services (HHS) may make limited exceptions for providers with limited internet connectivity including:
• Insufficient Internet Access (e.g. rural areas)
• EHR or CDSM vendor issues (e.g. technical problems, installation or upgrades temporarily impede access to CDSMs, vendors cease operations or CMS de-qualifies a CDSM)
• Extreme and Uncontrollable Circumstances (e.g. man-made or natural disasters; area infrastructure issues)

The CY 2017 MPFS Final Rule addresses the emergency medical condition exemption. CMS indicates while they acknowledge that most of these exempt emergent situations will occur primarily in the emergency department, these situations may arise in other settings as well. Further, they recognize that most encounters in the ED are NOT for an emergency medical condition.

The rule states, "To meet the exception for an emergency medical condition, the clinician only needs to determine that the medical condition manifests itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in: placing the health of the individual (or a woman's unborn child) in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part." In future rulemaking, CMS will detail how this exception will be indicated on the Medicare claim.

• Applicable imaging service means an advanced diagnostic imaging service (i.e. CT, MR and nuclear medicine, including PET) for which the Secretary determines (i) One or more applicable appropriate use criteria apply; (ii) There are one or more qualified clinical decision support mechanisms listed; and (iii) One or more of such mechanisms is available free of charge. X-ray, ultrasound, mammography, and fluoroscopy are explicitly excluded from the mandate.
• Applicable payment system means the physician fee schedule, the hospital outpatient prospective payment system and the ambulatory surgical center payment system.
• Applicable setting means a physician's office, a hospital outpatient department (including an emergency department), an ambulatory surgical center, and any other provider-led outpatient setting determined appropriate by the Secretary. Settings that are explicitly exempt from the policy are outlined in the below frequently asked questions.
• Appropriate use criteria (AUC) means criteria only developed or endorsed by national professional medical specialty societies or other provider-led entities, to assist ordering professionals and furnishing professionals in making the most appropriate treatment decision for a specific clinical condition for an individual. To the extent feasible, such criteria must be evidence-based. An AUC set is a collection of individual appropriate use criteria. An individual criterion is information presented in a manner that links: a specific clinical condition or presentation, one or more services and an assessment of the appropriateness of the service(s).
• Clinical decision support mechanism (CDSM) means the following: an interactive, electronic tool for use by clinicians that communicates AUC information to the user and assists them in making the most appropriate treatment decision for a patient's specific clinical condition. Tools may be modules within or available through certified electronic health record (EHR) technology or private sector mechanisms independent from certified EHR technology or established by the Secretary.
• Furnishing professional means a physician or a practitioner who furnishes an applicable imaging service.
• Ordering professional means a physician or a practitioner who orders an applicable imaging service.
• Priority clinical areas means clinical conditions, diseases or symptom complexes and associated advanced diagnostic imaging services identified by CMS through annual rulemaking and in consultation with stakeholders which may be used in the determination of outlier ordering professionals. This concept was not included in the statutory language.
• Provider-led entity (PLE) means a national professional medical specialty society or other organization that is comprised primarily of providers or practitioners who, either within the organization or outside of the organization, predominantly provide direct patient care.
• Specified applicable appropriate use criteria means any individual appropriate use criterion or AUC set developed, modified or endorsed by a qualified PLE.
• Qualified provider-led entity: To be qualified by CMS, a PLE must adhere to the evidence-based processes described in the 2016 MPFS Final Rule when developing or modifying AUC. A qualified PLE may develop AUC, modify AUC developed by another qualified PLE, or endorse AUC developed by other qualified PLEs.