January 1, 2017, is likely to be a red-letter day for radiology. As of this date, physicians ordering advanced diagnostic imaging exams (CT, MRI, nuclear medicine, and PET) for Medicare beneficiaries must, in compliance with the Protecting Access to Medicare Act of 2014, consult government-approved, evidence-based appropriate use criteria through a clinical decision support (CDS) system.
Whether these exams are conducted in physicians’ offices or hospital outpatient settings, entities conducting them will receive payment for their services only if claims for reimbursement confirm that the appropriate-use criteria was indeed consulted by the referring clinician. Payment is also contingent on confirmation of which CDS mechanism was used.
While the mandate itself is straightforward, it brings logistical complications: Every Medicare CT, MRI, nuclear medicine and PET study will be assigned by the CDS a “CDS number” (also referred to as a decision support ID, decision support score, or hashtag) that reflects the match between the imaging exam and the appropriate use criteria (AUC).
In order for CMS to issue payment, the CDS number—as well as other pertinent as-yet-unspecified data—must appear on every document pertaining to each imaging procedure making its way from the ordering physician to the radiology billing system—and be auditable.
Compliance with the mandate appears to be a tall order given the number of systems involved (in addition to the CDS, order placement, EMR, RIS, PACS, and billing) and the number of ambulatory imaging studies ordered annually in the U.S.
The latter figure exceeds 370 million and does not even include a share of the more than 400 million hospital imaging studies that are considered outpatient, according to Integrating the Healthcare Enterprise® (IHE), an initiative by healthcare professionals and industry to improve the way computer systems in healthcare share information.
The data flow and recordkeeping necessary to comply with the mandate, especially considering the high volume of studies and wide breadth of systems that come into play, would make manual input and re-entry of CDS numbers a costly, error-prone process, states IHE Radiology Planning Committee Co-Chair Teri Sippel Schmidt, MS.
Sippel Schmidt, who handles business development and standards for a Waterloo, Ontario-based workflow and diagnostic imaging solution vendor, adds that these problems would be further compounded under a manual umbrella were exams to be revised or rescheduled, or if multiple exams were to be ordered for a single provider visit.
Elisabeth A. Quam, executive director of the CDI Quality Institute arm of CDI Imaging (Minneapolis, Minnesota), co-founder of the eOrdering Coalition Work Group on Imaging Ordering, and chair of RBMA’s Federal Affairs Committee corroborates Sippel Schmid’s comments. That different referring clinicians utilize different systems only complicates matters further, she adds.
Moreover, say Sippel Schmidt and Quam, the “CDS number issue” affects players in every corner and at all points along the imaging continuum. “We’re talking about everyone who is a part of ordering, rendering, interpreting, and billing for imaging studies,” Quam states. “That number comes under consideration at every step of the way.”
After meeting with CMS about the situation, members of the eOrdering Coalition Work Group last year acknowledged what Quam deems a need for “an “industry push forward” to address the matter. They knew that “without it, we would all be in no shape to do anything but hand-write CDS information over and over and over again—with a a lot of margin for error.”
A proposal that IHE become involved in solving the problem was subsequently issued. “Each August, we have a call for proposals of clinical-information problems people want us to solve, and we vote on which ones we’re going to work on,” Sippel Schmidt explains. “This isn’t necessarily the most complex informatics problem we’ve ever seen, but it got the highest number of votes to take it on.”
IHE has since devised a standard CDS profile it believes can, if adopted industry-wide, be used to capture the required CDS data and send this CDS information through to the rendering provider and, in turn, the appropriate billing system.
The Clinical Decision Support Order Appropriateness Tracking (CDS-OAT) profile, which incorporates HL-7 order