AUC Program Updates: What You Need to Know The Protecting Access to Medicare Act, passed by Congress in 2014, included a provision requiring all clinicians ordering advanced diagnostic imaging services, including magnetic resonance imaging (MRI), computed tomography (CT) and nuclear medicine imaging procedures, to consult with appropriate use criteria (AUC) through a qualified clinical decision support mechanism (CDSM) in order for the furnished service to be paid by the Centers for Medicare and Medicaid Services (CMS). Echocardiography procedures are not included in this mandate. In this provision, AUC are defined as evidence-based criteria that assist ordering professionals to make the most appropriate treatment decisions for specific clinical conditions. Under the mandate, the ordering clinician and the clinician furnishing the service may be the same individual or different clinicians. Proposed Implementation Timeline In July, CMS released the proposed 2018 Medicare Physician Fee Schedule (PFS), which included a proposal to delay the implementation of this consultation requirement, originally slated for Jan. 1, 2018, by one year to begin Jan. 1, 2019. Additionally, CMS proposed instituting a voluntary reporting period for providers to test their workflow and claims processing starting as early as July 2018. The College is committed to ensuring the voices and concerns of cardiologists are heard in the implementation of the AUC Program. Approved AUC Only AUC developed by approved “provider-led entities” (PLE) can be used. As a qualified PLE, the ACC is approved to develop and modify AUC for advanced diagnostic imaging through June 2021. The College is currently working to update existing and create new AUCs for this program. In addition to ACC, CMS approved 16 other qualified PLEs to develop imaging criteria as of June 2017. Approved Vendors Coinciding with the release of the proposed PFS, CMS released an updated list of qualified CDSM vendors. To ensure the ACC’s AUC is available to members, the College is working to license its AUC content to qualified CDSMs. A list of CDSMs with licensed ACC content is available at www.ACC. org/FOCUS. It is important to note that the ACC’s imaging clinical decision support tool, FOCUS, is not an approved CDSM. Claims Processing CMS proposes that AUC consultation will be documented in the form of new codes and modifiers on the Medicare claim form. In the coming months, CMS will publish and finalize additional regulations with specific instructions on how ordering and imaging professionals are to participate in the AUC Program. Since the current proposal is open for public comment and subject to change, the ACC will continue to provide formal details as they become available. Next Steps For Members The AUC Mandate has the potential to significantly change practice workflow. The ACC strongly encourages all members to begin planning discussions with their practice, cardiovascular business line and health systems. It will be important to understand which AUC content and decision support vendors your office will use. The ACC continues to diligently develop comprehensive AUC policies in all areas of cardiovascular imaging. Additionally, the College has formed a multi-disciplinary AUC mandate work group to acknowledge and address member questions and concerns related to the AUC program as these details emerge. This group is currently in the process of developing communications and tools to help members prepare for implementation. CMS Releases Proposed 2018 Medicare Physician Fee Schedule and Hospital Outpatient Rules On July 13, the Centers for Medicare and Medicaid Services (CMS) released the proposed 2018 Medicare Physician Fee Schedule, addressing Medicare payment and quality provisions for physicians in 2018. Under the proposal, physicians will see a less than 0.1 percent conversion factor payment increase on Jan. 1, 2018. CMS estimates that the physician rule will decrease payments to cardiologists by two percent from 2017 to 2018. This estimate predicts a one percent reduction to changes in practice expense and a one percent reduction to changes in malpractice expense. It is based on the entire cardiology profession and can vary widely depending on the mix of services provided in a practice. The Physician Fee Schedule was released in tandem with the proposed 2018 Hospital Outpatient Prospective Payment System (OPPS) rule. The outpatient rule indicates a 1.75 percent payment update for hospitals. Highlights from both proposed rules include: Physician Fee Schedule • Proposals to implement the new appropriate use criteria (AUC) requirement for advanced imaging services (i.e., SPECT MPI, CT and MR). Specifically: º The proposal to require ordering professionals to consult with AUC through a qualified clinical decision support mechanism (CDSM) beginning Jan. 1, 2019, delaying this requirement one year. CMS also proposes the list of data elements that ordering professionals must report on the claims form under this program, including the use of new Healthcare Common Procedure Coding System (HCPCS) codes. The list of qualified CDSMs is posted on the CMS AUC Program website. º The proposal to consider the 2019 reporting year as a testing and education year. º CMS will seek comments on how the AUC program can support a Merit-Based Incentive Payment System (MIPS) quality measure. º Proposed hardship exceptions to the requirement to consult AUC and report data to CMS, including lack of face to- face patient interaction, clinicians who have been in practice for less than two years and the lack of availability and control over Certified Electronic Health Record Technology and internet connectivity. • Reduction of payment rates for certain items and services furnished by off-campus hospital provider-based departments from 50 percent of OPPS to 25 percent of OPPS. • A request for information regarding changes that could be made to regulations to relieve administrative burdens and better achieve program transparency, flexibility and innovation. • Updates to values for stress echocardiography, transthoracic echocardiography, electrophysiology (EP) device monitoring services, EP 3D mapping add-on services and extremity angiography radiological supervision and interpretation, resulting from previously directed reviews of work and practice expense inputs. More detail will be available after CMS posts supporting data tables. • Proposed values for new codes describing INR anticoagulation management billed per test regardless of where the test result is obtained and endovenous ablation of incompetent extremity veins. • A net reduction in expenditures resulting from adjustments to misvalued codes of 0.31 percent, missing the 2018 statutory target of 0.50 percent. The remaining 0.19 percent will be removed through an across-the-board reduction to all fee schedule services. • To align with MIPS requirements, clinicians and groups who successfully reported six quality measures for Physician Quality Reporting Program for 2016 will avoid the –2.0 percent penalty that was to be applied in 2018. This is a reduction from the required nine measures across three National Quality Strategy domains. Additionally, the maximum penalties for the Value-based Payment Modifier would be reduced from –4.0 percent to –2.0 percent for groups of 10 or more and –2.0 percent to –1.0 percent for groups of 10 or fewer. • CMS proposes the list of Level II HCPCS modifiers used to capture patient relationship categories required by Medicare Access and CHIP Reauthorization Act of 2015 for improved cost measurement. Voluntary use of these modifiers will begin on Jan. 1, 2018. • Changes to the Medicare Shared Savings Program Accountable Care Organizations, including the addition of chronic care management codes to the definition of primary care services for attribution purposes. Hospital Outpatient Prospective Payment System • Updates for policies related to ambulatory payment classifications (APCs), including the proposed addition of a new APC for certain imaging procedures, without contrast, to better classify services based on resource homogeneity. • CMS will seek comments on packaging policies that provide no separate payment for services and items such as drugs functioning as supplies in diagnostic tests and procedures or surgical procedures that are ancillary to a primary procedure. • The removal of six measures from the Hospital Outpatient Quality Reporting Program in either the CY 2020 or CY 2021 payment determinations, including OP-4: Aspirin at Arrival. • Similar with the fee schedule proposed rule, CMS seeks information on ways to achieve transparency, flexibility, program simplification and innovation. ACC staff are reviewing the proposed rules to identify additional topics of interest to members. More information will be forthcoming in the Advocate newsletter and on ACC.org. The College will submit written comments at the end of the summer. Not long before the final rules are released in the fall, experts will discuss federal legislative and regulatory topics at ACC’s 2017 Legislative Conference Sept. 10 – 12 in Washington, DC. Don’t miss this opportunity to learn about hot button issues facing cardiologists and to ensure the voice of cardiology is heard on Capitol Hill. Scan the QR code to access online registration.
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