According to “Will your Medicare reimbursement survive CMS’s new CDSM mandate?” from MedCity News, the CMS Clinical Decision Support Mechanism (CDSM) mandate will require new compliance measures when healthcare professionals order outpatient advanced imaging. The new mandate takes effect on January 1, 2022.
As part of the Protecting Access to Medicare Act, or PAMA, which was passed by Congress in 2014, CMS initiated the Appropriate Use Criteria (AUC) Program, which includes the CDSM. The late addition to the mandate requires healthcare professionals to consult an AUC software program when ordering advanced imaging tests and then issues a certificate of compliance to the rendering provider so that they will be reimbursed through Medicare.
Despite the AUC program being designed around supporting diagnosing physicians when ordering advanced imaging tests, it can negatively impact those same physicians if they fail to receive the certificate of compliance directly from the ordering provider. For healthcare professionals billing Medicare Part B, the impact on revenue can be significant, with the potential to lose the revenue outright. The only exceptions are for inpatient services billing for Medicare Part A, emergency patients, and ordering physicians with significant hardship, such as more remote rural locations or those with poor or no internet access.
The mandate requires referring healthcare professionals who order an advanced imaging test, including magnetic resonance imaging and computed tomography, to consult CMS-approved CDSM software with AUC to determine if a test is applicable. If warranted, the software generates and forwards a certificate of compliance, including to the appropriate rendering provider. This certificate is held in the patient’s medical record with codified results on the outgoing imaging claim going to Medicare.
While the ordering provider is responsible for the consultation, the new mandate instead places the risk on the rendering provider. In the future, CMS may require noncompliant healthcare professionals with a high rate of nonadherent procedures to gain additional approval or face monetary risk.