Radiology practices across the country can no longer bet that CMS will delay the mandate to consult appropriate use criteria (AUC) scheduled to commence in 2020—but that did not stop the American Medical Association (AMA) from passing a resolution at its annual meeting in Chicago requesting yet another delay in implementation. 

According to Strategic Radiology chair and CEO Arl Van Moore Jr, MD, FACR, the resolution is likely a shout into the wind, as turning back the clock yet again would require new legislation to reconcile the differences in PAMA (enacted 2014) and MACRA (enacted 2015). Dr Moore is the chair of the ACR delegation to the AMA.

“While the AUC is PAMA-mandated, there remains a lot of pushback from other specialties, basically because of what seems to be a lack of understanding of the legislative challenges related to the two independent pieces of legislation,” Dr Moore said.  “On behalf of all of our practices, the ACR showed up at the AMA to present a special session to help others understand the potential of these tools to improve care.”

Jacqueline Bello, MD, FACR, chair of the ACR Commission on Quality and Safety, and ACR CEO William T. Thorwarth Jr., MD, FACR, shared history, CDS basics, and implications for referring physicians and radiology practices in a session called “Avoid PAMA Drama.”

Following their presentation, a physician panel that included radiologist Terry Matalon, MD, FACR, an early adopter of radiology CDS in 2014 at Einstein Medical Center, internal medicine physician Mike Cheng, MD, who shared his experience with a training curriculum for medical students that utilizes AUC, and Molly Craven, DO, a family practice physician, who described her experiences with an outpatient CDS tool. 

The takeaway was that not only can a successful implementation of CDS for imaging orders help improve the value of health care, but it can provide much-needed support to referring physicians, many of whom have received scant training in proper ordering.

“Strategic Radiology practices are gearing up for this now,” continued Moore, “and independent practices have a lot riding on successful implementations with their hospital partners. Lisa Mead (executive director of SR’s Patient Safety Organization) has played a real leadership role in mobilizing Strategic Radiology members to develop shared materials to educate their hospital partners and referring physicians.”

Paving the Way

During the ACR presentation at the recent AMA meeting, Dr. Matalon shared a brief video that illustrated the value that the CDS implementation has created at Einstein Healthcare Network, in which many physicians weigh in on the contribution the tool has made to improving care.

Dr. Cheng  presented on a program developed at the University of Chicago to expose internal medicine interns to the ACR AUC, now integrated into the internal medicine curriculum. The curriculum includes lectures and simulated case studies that utilized Radiology-TEACHES, developed by radiologists at Baylor University Medical School to teach medical students about the image ordering process and introduce them to CDS.

An ACR case study that describes the program features a testimonial from an internal medicine intern who experienced the curriculum saying he already is using what he learned when ordering ankle x-rays at an acute care clinic: “I had no idea that certain X-rays carry much more potent radiation than certain CT scans—the appropriateness criteria is a hidden gem and a useful resource that I’ll definitely be using going forward.”

In sharing her experience with CareSelect at Brookside Family Medicine in Traverse City, Mich in a different ACR case study, Dr Craven said: “I’m not always certain that I’m ordering the correct study, especially when it comes to imaging that may require one or more types of contrast. During a busy workday, I would have to pick up the phone and speak to one or more radiology employees, before ultimately interrupting a radiologist to discuss my question regarding study type.”

A Year to Get it Right

Beginning January 1, 2020, any physician who orders advanced imaging for Medicare-eligible patients (with the exception of inpatients and patients with “an emergency medical condition” as defined in the Social Security Act) must consult AUC using an approved CDS mechanism (CDSM).

During 2020, which CMS calls a trial year, referring physicians will not be required to comply with the recommendation delivered by the CDS mechanism (CDSM) they use to place the advanced imaging order. Likewise, claims will not be denied in 2020 if they do not contain the proper AUC information, which is yet to be released. (CMS plans to issue HCPCS G-codes that will correspond to each approved CDSM and modifiers that will indicate whether the order adheres to AUC guidelines or if an exception applies.)

“The first year, 2020, gives us time to get this right, and practices who start now can use this process as a practice improvement activity for the QPP,” said Mead, SR–PSO executive director. “If the tools are easy to use—and that means an integration with the EHR in hospital settings—they can really help to add value to medicine.”