As of Jan 1, 2018, the United States healthcare reform requires that physicians implement clinical decision support (CDS) software. This was done to ensure the appropriate use criteria (AUC) are being followed when ordering non-emergency, outpatient imaging tests. The Centers for Medicare and Medicaid Services (CMS) require that physicians use CDS software that has been certified by the CMS. Otherwise, they may not receive the full payment amount for the patients who receive diagnostic imaging services at their facility. This includes Medicare and Medicaid.
Clinical Decision Support Software Requirements
The technical term that CMS uses (for the clinical decision support software) is the clinical decision support mechanism (CDSM). The Centers of Medicare and Medicaid Services requires that the CDSM physician uses an electronic, interactive tool. The tool that effectively communicates the appropriate use criteria to the doctor. In addition, the tool must assist the physician in making the appropriate treatment choice for the patient. Of course, it needs to be based on his or her clinical condition. All the qualified CDSMs are listed on the CMS website by June 30 each year.
Exceptions:
There are some exceptions to the CDSM requirement. For example, exceptions are made for imaging orders from professionals for an inpatient, for emergency services or for a payment that will be made under Medicare Part A. In addition, professionals granted a significant hardship exception to the Medicare EHR Incentive Program for that specific year.
Meeting the Appropriate Standards with CDS Software
To ensure the health insurances’ acceptable standards are met, CDS software is based on the appropriate use criteria. They are set by a variety of provider-led entities (PLEs). The entities on this list are approved by the CMS to develop, endorse and/or modify the appropriate use criteria.
Some of the PLEs on this list include the:
- American College of Radiology (ACR).
- Massachusetts General Hospital, Department of Radiology.
- Society for Nuclear Medicine and Molecular Imaging (SNMMI).
- Center for Diagnostic Imaging (CDI) Quality Institute.
The Centers of Medicare and Medicaid Services’ Goal
CMS hopes that this regulation will make sure that advanced imaging exams (e.g., MRIs, CTs, PETs, etc.) are only performed when they are necessary. The decision to perform the test is based on the patient’s condition. This regulation may decrease how many additional imaging tests are ordered. For example, because the first exam was inappropriate for the patient’s symptoms.
Clinical Decision Support Software and Radiology
These health care reform changes affect advanced outpatient imaging services. Also, it affects magnetic resonance imaging (MRI), computed tomography (CT), the positron emission tomography (PET) and the single-photon emission computed tomography (SPECT) scan.
Clinical decision support software is designed to reduce the number of unnecessary radiology tests. The tests are performed by ensuring that the appropriate criteria are met ahead of time. Furthermore, this will help reduce health care costs. When it comes to radiology, CDS quickly determines which diagnostic tests or imaging exams a patient needs. It’s based on his or her specific symptoms.
Another benefit of CDS software is that the number of rejected health insurance claims, resulting from tests performed for patients neglecting to meet the acceptable guidelines will also decline. This saves the imaging centers and radiology departments both time and money.
Radiologists Need to Check with Doctors
Radiologists need to make sure that the physicians who are ordering imaging tests are doing so through a CDS system. Otherwise, the radiologists may not get paid. This is according to Steve Herman, M.D., who is a thoracic radiologist as well as the founder and marketing director of the clinical decision support company MedCurrent.
The Centers for Medicare and Medicaid Services High-Priority Clinical Areas
To decrease the number of expensive and/or unnecessary imaging exams being performed, CMS wants CDS software implemented in a few high-priority clinical areas.
These clinical areas include patients who are experiencing:
- Hip pain.
- Headache.
- Low back pain.
- Cervical/Neck pain.
- Shoulder pain (including a suspected injury to the rotator cuff).
As well as those who do, or may have:
- Lung cancer (suspected or diagnosed, metastatic or primary).
- A pulmonary embolism.
- Coronary artery disease (diagnosed or suspected).
Beginning Jan. 1, 2020, doctors whose imaging exams are not meeting CMS’ AUC requirements will have to obtain prior authorization from CMS before a patient receives a scan. Not receiving a prior authorization will most likely result in CMS rejecting the claim.