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The Practice EHR Blog

Appropriate Use Criteria Changes: What You Need to Know for 2020

Posted by Karna Morrow, CPC, RCC, CCS-P, Implementation Manager on Dec 5, 2019 8:00:00 AM


It is hard to believe that the end of another year is just around the corner. This is a busy time in healthcare. CMS will soon release the Final Rules and confirm changes to the reimbursement and reporting guidelines for 2020. Not all changes impact each specialty in the same way. But there is one change that will impact many of Practice EHR practices.

The Appropriate Use Criteria (aka Clinical Decision Support) goes into effect January 1, 2020 and changes the way in which an order is placed for advanced imaging for a Medicare patient. If you place an order for an MRI, CT, nuclear medicine study or PET for a Medicare patient an additional step will be required to complete the order. This applies to those ordering imaging to be done in an outside facility (hospital/imaging center) and imaging that is performed within your own practice.

Key Takeaways

The clinician will enter the patient’s information (age/presenting problem) into a separate software system referred to in the guidelines as a “Clinical Decision Support Mechanism (CDSM).” Using an algorithm developed with input from a variety of medical specialties, the CDSM will return a list of the most appropriate imaging studies for that condition. Each recommended imaging study will include a score rating the appropriateness. For example, an MRI with contrast may be listed as ‘appropriate’, but with a score of 7. An MRI without contrast may also be in the list as ‘appropriate’, but with a score of 9. A clinician may still request or select the imaging study they originally felt was best; however, the total score for all imaging ordered within the calendar year will be tracked by CMS. Ordering advanced imaging that is viewed as less appropriate may impact the ordering provider’s reimbursement in future years.

The facility reporting the technical component of the imaging study to Medicare will require two additional pieces of information from the ordering provider. When the imaging study is selected within the system, the CDSM will generate a result such as “adhered, ” “didn’t adhere” or “didn’t apply.” This result will translate into a modifier that will be attached by the facility billing department to the claim. This information will need to be communicated by the ordering provider to the facility. The second piece of information will be the name of the CDSM that was consulted. This information will be translated into a G code and entered as a separate line item by the facility.

Practice EHR will provide a warning within the system that an order has been requested for an advance imaging study; however, the practice will need to consult a separate software system (CDSM) to complete the process. CMS has approved multiple CDSMs. The list is available here. We recommend that you contact the facility where your patients will receive their imaging study, speak with the Radiology Department Manager and learn their new process. The facility may have a portal that can be used for meeting this requirement.

If we can be of further assistance, or help you learn more about this requirement send us a message.

Topics: Healthcare Office Management, Regulatory Updates, Industry Update