Ordering Advanced Imaging? Get Ready for New Medicare Rules

Kerry Dooley Young

June 11, 2019

Starting in January 2020, Medicare will require that providers use a certified clinical decision support (CDS) system when ordering advanced imaging tests for eight common conditions. Physicians should start preparing for the changes now, according to the authors of an article published online June 10 in the Annals of Internal Medicine.

Keith D. Hentel, MD, Weill Cornell Medicine, New York City, and coauthors addressed the challenges ahead for physicians with the implementation of so-called appropriate use criteria (AUC).

The added layer of administrative work is designed to reduce inappropriate use of MRI, nuclear medicine, and CT. The priority conditions covered in the AUC program include coronary artery disease, suspected pulmonary embolism, headache, hip pain, low back pain, shoulder pain, suspected rotator cuff injury, suspected or diagnosed lung cancer, and cervical or neck pain.

Medicare appears on track for the January 1, 2020, kickoff date for the program. Potential penalties for noncompliance and inappropriate ordering patterns won't take effect immediately.

Medical practices will need time to get set up to comply with the new Medicare regulation, Hentel told Medscape Medical News in an interview.

"The first year there's going to be no financial penalties, but for any type of culture change, any type of process improvement, you need time to make it happen," he said.

Hentel said Medicare's AUC program is not unlike the processes already in place for preauthorization that insurers use.

"Most physician offices are used to a process like this in terms of preauthorization," Hentel said. "This is better than preauthorization in many ways."

With preauthorization, physicians may have to guess how an insurer will view a request for a service for a patient. With Medicare's approach, there are more clear criteria that have been hashed out by experts such as medical societies. Physicians will use CDS programs, which are electronic portals through which the need for imaging is assessed.

"For this, the criteria are transparent. They are posted" on the Internet, Hentel said. "There's no mystery to that."

Still, this requirement will add to the bureaucratic burdens physicians face, he said.

"Nobody is looking for one more interaction with the electronic health record [EHR]," Hentel said.

"It's very well intended, but so are a lot of things that we do in medicine," Hentel added. "At the end of the day, it's maybe a little more time that you don't spend with the patient, because you're busy answering questions on the computer."

Medical practices and physicians may use different strategies to comply with the new rule, Hentel and coauthors write. They may use a single CDS mechanism or try a combination approach, such as integrating an EHR and a portal. The authors recommend evaluating CDS systems in terms of both clinical content, such as potential conflicts with local practices, and the effect on clinicians, such as the number of clicks required and the potential for alert frequency.

In addition, practices need to prepare for costs associated with the program, Hentel and coauthors note.

"Many organizations have not budgeted for annual licensing fees, some of which are substantial, and will need to allocate financial resources," they write.

In talking with Medscape, Hentel expressed optimism that the planned AUC program will deliver significant positive results.

"It is true that there is currently not evidence that such a wide-scale implementation of computerized decision support will work," he said. "But there are there are smaller studies that show if it's done right, it can do it."

The Centers for Medicare & Medicaid Services (CMS) has addressed issues that affected the results of the largest study to date, a Medicare imaging demonstration project, Hentel said.

Responding to earlier concerns raised in the medical community, CMS postponed the implementation of the AUC. In 2017, the agency delayed the current effective date of January 1, 2020.

Earlier this year, the American Academy of Family Physicians joined more than 20 other medical groups in asking Congress for further delay. So far, though, CMS has not given indications that it will hold off further on the AUC program. The agency's stance will become clear when it releases its draft version of the 2020 Medicare payment rule covering physician payment. This is expected in the coming weeks. CMS has already submitted the draft rule to the White House's Office of Management and Budget for a final review before it is publicly released.

"I think they probably will go through with it," Hentel said of the planned phase-in of AUC criteria with CDS. "They realize that there are going to be issues. That's why they've put in a 1-year operational and readiness testing period."

The authors of the article reported financial relationships with the following organizations: the Agency for Healthcare Research and Quality, Adient Medical, Enlitic, GE, Medicalis Corp, Memorial Sloan Kettering Cancer Center, Nuance, Oliver Wyman, Practicing Wisely, Siemens, the Society of Interventional Radiology Foundation, and the University of California QPLE.

Ann Intern Med. Published online June 10, 2019. Abstract

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