CMS Holds Line on CDS Deadline, Includes Outpatient Imaging Sites, Extends Site-neutral Pay

In the spirit of equality, the agency also proposed that the mandate to consult AUC prior to ordering advanced imaging be extended to include independent diagnostic testing facilities (IDTFs), physician offices, hospital outpatient sites, and emergency departments (the latter included in previous rule-making).

August 1, 2018

Providers that have stood on the clinical decision support (CDS) sidelines as the implementation deadline approaches received a strong signal that CMS intends to stand firm on the requirement to implement appropriate use criteria (AUC) and CDS in 2020, with the July 12 publication of the proposed 2019 Medicare Physician Fee Schedule (MPFS). 

In the spirit of equality, the agency also proposed that the mandate to consult AUC prior to ordering advanced imaging be extended to include independent diagnostic testing facilities (IDTFs), physician offices, hospital outpatient sites, and emergency departments (the latter included in previous rule-making). 

CMS did nudge the AUC/CDS start date 6 months—from July 1, 2019, to January 1, 2020—in order to allow time to develop claims processing instructions and declared 2020 a test period during which AUC consultation must be reported on the claim, but CMS will pay claims whether or not they include the correct information during the trial year. The actual consultation may be performed by clinical staff working under the direction of the ordering professional. Providers are seeking further clarification on that point.

G-codes to affirm AUC consultation were proposed as the confirmation mechanism, but CMS will continue to work with industry and providers on development of a unique consultation identifier, an aim that has occupied radiology vendors, providers, and members of the Integrating the Healthcare Enterprise for many months.

In an initial overview on its web site, the ACR expressed appreciation for CMS’s decision to move forward with the implementation of appropriate use criteria and clinical decision support for all advanced medical imaging services, and provided a preliminary overview of the plan’s overall impact on radiology, including the following: 

AUC/CDS Hardship Exemptions. CMS proposes that ordering professionals may be exempted from consulting AUC if they have insufficient internet access, EHR or CDS mechanism issues, or extreme or uncontrollable circumstances, such as an act of nature or man-made disaster.

Site-neutral Payment. In a move that could dampen hospital appetite for employing physicians, CMS proposes to pay the same amount for outpatient services provided in hospital-based outpatient locations and physician offices. Last year, CMS implemented its site neutral payment policy to off-campus hospital-based imaging facilities and now proposes extending that policy to physician visits and other services take place in off-campus hospital based facilities, currently paid under the more generous Outpatient Prospective Payment System (HOPPS). The policy was contained in the proposed 2019 HOPPS and Ambulatory Surgical Center payment system rule, released July 26. Modern Healthcare predicted a "battle royale" between CMS and hospitals on this proposal, which it said would result in $610 million in savings for Medicare and for patients, $150 million.

Conversion Factor. The conversion factor for 2019 is estimated to be $36.0463, which reflects a 0.25 percent update specified by MACRA and a -0.12 percent budget neutrality update, resulting in a slight increase over the current conversion factor of $35.9996. Dave Polmanteer, SR director of analytics and business intelligence, will provide MPFS impact analysis reports to SR members.

Radiologist Assistant Supervision. CMS proposed to reduce the supervision requirement for radiologist assistants from personal supervision to direct supervision for work performed according to state law and state scope of practice rules.

CMS also took steps to reduce administrative complexity in a rule that itself weighed in at a hefty 1,472 pages.  A number of provisions aimed at streamlining E&M payment were proposed, including allowing practitioners to use time in assigning a visit level and documenting the E/M visit; enabling the practitioner to focus on what has changed when documenting a visit (rather than re-entering information collected in a previous visit); allowing physicians to review rather than re-enter information input by staff members; new single blended payment rates for office/outpatient E&M level 2 through 5 visits, with a series of add-on codes to reflect resource use; and multiple procedure payment adjustments that would apply when E&M visits occur in conjunction with other visits.

Not everyone is cheering the simplified E&M codes. The executive director of the Community Oncology Alliance complained to Modern Healthcare that the simplification results in physicians being paid the same for "evaluating a case of sniffles and a complex brain cancer." He said, “It is the antithesis of value-based health care and cheapens the medical care seniors are entitled to under Medicare.”

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