Is radiology ready for clinical decision support?

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Starting in January 2020, the testing period will begin for new federal rules requiring medical imaging exams to be ordered using appropriate use criteria (AUC) and clinical decision support (CDS). The question is, are radiology practices ready?

That depends on whom you ask. While most in radiology are vaguely aware that AUC/CDS is looming, many aren't quite sure what it means. And indeed, some practices appear to be hoping that the U.S. Centers for Medicare and Medicaid Services (CMS) will revert to past habits and simply postpone the entire exercise.

But that's unlikely to happen. Instead, radiologists, administrators, and business managers should take advantage of the 2020 testing period to prepare for AUC/CDS. More importantly, they should reach out to referring physicians to ensure that they are ready as well. If they don't, they could start to see interruptions in Medicare reimbursement starting in 2021.


Appropriate use criteria and clinical decision support are designed to tackle the burgeoning problem of inappropriate utilization of healthcare resources -- in this case, advanced imaging exams. Studies have found that from 20% to 30% of advanced imaging exams in the U.S. are believed to be unnecessary.

AUC/CDS attacks this problem by requiring referring physicians to order exams using clinical decision support that's based on accepted appropriate use criteria for when a particular exam is indicated for a clinical scenario.

With respect to Medicare, the new AUC/CDS payment rule was established as part of the Protecting Access to Medicare Act (PAMA) and was codified in the final Medicare Physician Fee Schedule (MPFS) for 2018. CMS has stated that the rule will undergo a one-year testing period starting in January 2020, with full implementation in 2021.

What does "full implementation" mean? Starting January 1, 2021, when the law is fully implemented, CMS will financially penalize radiologists if they perform imaging scans that were ordered by referring physicians who didn't use AUC/CDS. Sounds bad, right?

Sandy Coffta from Healthcare Administrative Partners.Sandy Coffta from Healthcare Administrative Partners.

Fortunately, radiology practices can take advantage of the testing period throughout 2020 to take proactive steps to ensure that referring physicians comply with using AUC/CDS when ordering imaging. And while full implementation is a year away, it's never too early to start.

"Everyone in the country needs to get on this," said Sandy Coffta, vice president of client services at Healthcare Administrative Partners, which offers medical billing and coding services to radiology practices. "This is forcing radiologists to make it a priority to do that outreach [to referring physicians]."

In particular, it's incumbent upon radiologists to communicate to their referring physicians. The onus is on the radiologist to ensure that clinical decision support is used, but radiologists don't have to worry about whether the orders they get meet appropriate use criteria.

In the end, the radiologist will not be penalized even if the appropriate criteria are not met, stressed Dr. Charles Kahn, a professor of radiology at the Hospital of the University of Pennsylvania and vice chair of the department of radiology at the university's Perelman School of Medicine in Philadelphia.

Even if an imaging test does not match AUC, "as long as it goes through decision support, radiology will be reimbursed for the service," Kahn said. "It does not matter if the test is deemed to be appropriate or not."

Why now?

Kathryn Keysor, American College of Radiology.Kathryn Keysor, American College of Radiology.

Why the sudden focus on appropriate use and clinical decision support? Neither is new, but what is new is Medicare's enforcement of the criteria, according to Kathryn Keysor, the senior director of economics and health policy at the American College of Radiology (ACR).

"The appropriate use criteria have been around for many years," said Keysor, noting that PAMA was passed in 2014. "This [law] is a way of mandating that they be used."

But while the law appears to address the issue of selecting inappropriate imaging, it has a dual effect of potentially lowering Medicare healthcare expenditures -- a major focus of CMS.

"This is definitely about reducing costs to the Medicare system," Coffta said. "Healthcare costs grow every year at a faster rate than income."

With imaging presenting a high price tag, public payors such as Medicare have explored ways of curbing unnecessary imaging through various avenues, Keysor said.

"Imaging is a high-dollar service, and they are looking for ways to control utilization," she said.

And Medicare and Medicaid can represent a meaningful portion of the total income of a radiology practice, Kahn noted.

"For most departments, Medicare represents a significant part of their book of business," he said. "Depending on the practice, it can make up anywhere from 5% to 50% [of total income]."

Looking for outliers

Dr. Charles Kahn, University of Pennsylvania.Dr. Charles Kahn, University of Pennsylvania.

Kahn believes that, instead of being designed to scrutinize every physician's orders for imaging, the AUC/CDS rules are primarily aimed at detecting outliers, or physicians whose ordering patterns are not reflective of best practices or based on the best evidence available.

"It wants to identify those providers who are consistently ordering tests that are not appropriate," Kahn said. "All of us want to make sure that the tests are being done for the right reason, that the ordering is evidence-based where possible, and is based on consensus and best judgment."

For medical imaging procedures, appropriate use criteria have been developed by highly credible organizations, such as the ACR, the National Comprehensive Cancer Network, and the American College of Cardiology, Kahn noted.

It remains to be determined how CMS will precisely define an outlier -- loosely defined as a physician whose prescribing practices are irregular and inconsistent with that of his or her peers -- but Keysor noted that CMS will be focusing eight priority clinical areas when it evaluates imaging ordering patterns and decides which physicians should be flagged as outliers. These clinical areas are listed below:

β€œAll of us want to make sure that the tests are being done for the right reason.”
β€” Dr. Charles Kahn, University of Pennsylvania
  • Coronary artery disease (suspected or diagnosed)
  • Suspected pulmonary embolism
  • Headache (traumatic and nontraumatic)
  • Hip pain
  • Low back pain
  • Shoulder pain (to include suspected rotator cuff injury)
  • Cancer of the lung (primary or metastatic, suspected or diagnosed)
  • Cervical or neck pain

Some common physician ordering practices are being discouraged because they are not evidence-based, Coffta noted.

"Ordering an MRI for low back pain is not appropriate," she said.

Data will be collected in an ongoing fashion so that CMS will be able to identify referring physicians who are failing to meet the AUC as outlined, according to Keysor.

"Down the road, you will be possibly flagged as an outlier if you are continually not following the criteria," she explained.

CMS will likely not pursue referring physicians who occasionally deviate from guidelines for imaging, but it will spot those who are repeat offenders and do not heed the AUC, in Kahn's view.

"CMS will monitor folks," Kahn said. "It is anticipated that people will not follow the guidelines 100% of the time. In fact, [most] people do not."

Getting the word out

β€œYou will be possibly flagged as an outlier if you are continually not following the criteria.”
β€” Kathryn Keysor, American College of Radiology

For its part, the ACR has been holding webinars on AUC/CDS for members and nonmembers, and it has been reaching out to key stakeholders to spread the word about the imminent introduction of the law in 2020 and its financial effect starting in 2021.

In addition, the ACR has indicated that members can contact the group with any questions about how the law will be rolled out. ACR will provide responses and resources to assist radiology practices and other facilities in making a smooth transition to an environment in which exams are ordered with clinical decision support.

Reaching out to referring physicians is a key task right now for radiology practices.

"We are encouraging our members to send letters to their referring physicians and let them know that this is coming and let them know to contact ACR if they have questions," Keysor said.

How to comply

Hospitals and other facilities that order imaging exams have two paths for complying with the clinical decision support rules. One is to use commercially available software that is based on ACR's appropriate use criteria. These often will integrate with a facility's electronic health record (EHR) system.

The second is to use one of three qualified clinical decision support mechanisms that have free online portals available:

The law requires that at least one free option is available to consult AUC/CDS, Keysor notes.

"Instead of paying for a system that is integrated with their HER system, they can just go to a website and do the consultation at no charge," Keysor explained.

Is radiology ready?

So how ready is radiology for the new rule and integrating it into practice? Observers differ on the preparedness of the specialty.

"I think most [radiology] departments in the U.S. are moving pretty quickly to implement this," Kahn said.

Coffta, however, has a less optimistic view about how ready other healthcare facilities are for AUC/CDS.

"I think the degree of readiness varies pretty widely," Coffta said. "Some are already using it, while others are opting to 'get to it later,' while some are sitting back and waiting."

Some of the procrastination may owe to the fact that CMS has a history of postponing major initiatives, Coffta said.

In the end, one of the ingredients to a successful implementation of AUC/CDS will be healthy relationships between radiologists and referring physicians, referring physicians and hospitals, and hospitals and radiologists, Coffta added.

"You need all of these relationships to be working" for the rule to be effective, she said.

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