The 2014 Protecting Access to Medicare Act (PAMA) now includes a provision that requires clinicians to consult with appropriate use criteria (AUC) through a qualified clinical decision support mechanism when ordering advanced diagnostic imaging services in order to receive payment approval from the Centers for Medicare and Medicaid Services (CMS).
Examples of such advanced imaging services include CT, PET, nuclear medicine and MRIs.
A Clinical Decision Support Mechanism (CDSM) provides interactive decisioning tools designed to communicate AUC information to the user and assist them in making the most appropriate treatment decisions for a patient’s specific clinical condition. CMS has authorized specific CDSMs to be qualified for the Appropriate Use program.
This notice is to inform you that Eye Care Leaders has committed our technical resources to other priority development projects and will not pursue direct integration with an Appropriate Use CDSM at this time. It is important that all Medicare providers that order advanced imaging services for their patients should contact one of the CDSMs listed below prior to December 31, 2021 and establish CDSM services. Beginning on January 1, 2022, any claims that fail to provide proper AUC consultation information will not be paid.
The following CDSMs have been identified as suitable standalone options for Eye Care Leaders software users.
|Medical is Clinical Decision Support Mechanism||Medicalis CDS||Fee based|
|National Decision Support Company CareSelect ™*||Careselect CDSM||Free tool available|
|AIM Specialty Health Provider Portal ®*||AIM Specialty Provider Portal||Free tool available|
|Cranberry Peak ezCDS||Cranberry Peak ezCDS||Fee based|
|Sage Health Management Solutions Inc. RadWise ®||RadWise CDS||Fee based|
|InveniQA’s Semantic Answers in Medicine ™||Inveniqa SAM||30-day free trial then 19.95 per month per provider|
|INFINX CDSM||INFINX CDSM||Fee based|
|LogicNets AUC Solution*||LogicNets||Pay per use option|
|MedCurrent OrderWise ™||OrderWise CDSM||Fee based|
*Free Tool Available
Additional information regarding the Appropriate Use Criteria Program may be found on the CMS.gov website:
Frequently Asked Questions
What will the CDSM do?
For each Appropriate Use Criteria consultation, the CDSM must:
- Determine and generate documentation on whether the service ordered would or would not adhere to AUC or whether the AUC consulted was not applicable to the service ordered
- Include the name and National Provider Identifier (NPI) of the ordering professional
- Include a unique consultation identifier, which will be used by the servicing provider to append the claim
Why is ECL not developing their own Clinical Decision Support Mechanism (CDSM)?
The process to become and then maintain a qualified CDSM under CMS is quite lengthy and complex and would require significant technical and administrative resources. Since there are qualified CDSM options already available, ECL has decided to dedicate those resources to other high priority projects.
Can you integrate with an existing CDSM?
We are not pursuing any integration options with existing CDSMs at this time. It may be an option in the future.
I do not bill for or perform any advanced diagnostic imaging services in my facility. Do I still need a CDSM?
If you order any advanced diagnostic imaging services, then you need a CDSM. The Appropriate Use Criteria consultation applies to the order itself, not the rendering of the service. Therefore, the ordering provider must consult the CDSM when advanced diagnostic imaging services are required.
There are a lot of CDSM options on this notice, how do I know which one to pick?
The CDSMs listed on the notice were selected for their standalone product availability and likely ease of use (just register and then use a un/pw to access the portal). There may be other features available that may make one CDSM preferable over another. Please use the links provided to review the solutions and then contact the company directly to learn more.
How much will a CDSM cost?
Some companies offer a free CDSM solution, but the functionality may be limited as compared to fee-for-service solutions. Fee information has been provided on the notice when available on the company’s website. Please contact the company directly for detailed cost information.
Can I get a demo of the product?
Most of the products listed offer demonstrations either by appointment or by a video.
Does the Appropriate Use Criteria program apply to me?
The AUC program applies to all Medicare providers that order any advanced imaging services for their Medicare patients.
What is an advanced imaging service?
Advanced diagnostic imaging services are defined as:
o Diagnostic Magnetic Resonance Imaging (MRI)
o Computed Tomography (CT)
o Nuclear Medicine,
o Positron Emission Tomography (PET)
- ADI procedures do NOT include x-ray, ultrasound or fluoroscopy procedures