Director’s Corner – Checking the right box

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Physicians will have to be aware of changing pre-authorization mandates.

Dear Director,


I’ve been told by radiology that I need to start checking the right box when it comes to radiology ordering.  Often, I find the computer tells me I’m not ordering the right test.  This is frustrating and wasting my time.  What’s going on?

Consulting an Appropriate Use Criteria (AUC) via an electronic Clinical Decision Support (CDS) system has been on our radiology colleagues’ radar for years. Now that the start of a new government mandated program is just around the corner, emergency physicians are beginning to pay attention.  As part of the Protecting Access to Medicare Act (PAMA) of 2014, Congress mandated the use of AUC via CDS for advanced imaging in Medicare patients in the outpatient setting.

While significantly delayed, it does look like it’s officially starting Jan. 1, 2020.  PAMA required CMS to develop and implement this system.  Clinical guidelines and electronic tools have already been developed and your hospital has most likely built these into your EMR via a third party vendor.  The benefit to the provider is that Medicare may eliminate the need for pre-authorization if CDS is being utilized correctly.  Though we don’t typically have to deal with this, pre-authorization is definitely a burdensome step for private offices and imaging departments.


Who and what are affected

Clinical decision support is required for all Medicare patients in the outpatient setting, ranging from physician’s offices to ambulatory surgery centers and the ED.  Although the program currently is based on the Medicare patient population, I suspect most hospitals won’t be able to quickly differentiate insurance status in their EMR order section. As commercial insurance will develop similar requirements down the road, expect your radiologists and hospital to make this a requirement on all ED patients. This program includes patients in the hospital in observation status, but does not include admitted patients.

Most hospitals will not have a system in place that separates out admitted from obs patients in the ordering section of the EMR. Expect the hospitalists to also complete the documentation requirements for their patients.  Interestingly enough, CMS is walking a fine line between our mandate to provide a complete and thorough medical screening exam that is inclusive of all necessary testing to rule out an emergency medical condition, and then states that CDS documentation is needed for all non-emergency conditions.  I actually thought everyone was an emergency via EMTALA until proven otherwise, but CMS does provide language of what an emergency is regarding CDS:

The term “emergency medical condition” means—


(A) a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in—

(i) placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy,

(ii) serious impairment to bodily functions, or

(iii) serious dysfunction of any bodily organ or part;

ACEP has tried to block the ED being included in this process, but it does not appear that they’ve made progress. Interestingly enough, the group that it doesn’t apply to in the ED is the critically ill and they’re probably the easiest patient subset to identify the right AUC.

If there is any good news, it’s that we won’t need to be searching for the correct AUC box on routine imaging.  This program is for advanced imaging which includes CT, MRI and nuclear medicine/PET scans.  I don’t order a lot of MRI’s or nuc med studies but about 30% of our main side patients get CTs so I know I’ll be deep in the search to select the right AUC box.

Is there a utilization problem?

I’ve been tracking CT utilization among my docs for years and while I’d like to believe that every test ordered is appropriate, at the very least, there is clearly a wide variation in how clinicians order advanced imaging.  CMS has identified eight priority areas of widespread variation in utilization and where evidence seems clear as to what tests are needed.  Five of these are patients commonly seen in the ED and include: suspected PE, headache (traumatic and atraumatic), hip pain, back pain and neck pain.  While most of us go to great lengths to not order MRIs on back pain patients and I think we’ve come a long way on reducing radiation for minor head trauma, I continue to see chest CTAs to rule out PE ordered on patients with negative d-dimers, so I know we’re not perfect.

These new documentation rules will apply to all CT and MRI tests ordered.  I’ve had extensive conversations with our radiologists and while they don’t think we’re perfect in our ordering, their bigger concern is with the outpatient physician, many of whom still illegibly write imaging orders on prescription pads.  As ER docs, if we’re not sure what test we want, we frequently call the radiologist for help.  I had a trauma patient recently and wanted a CT of T10-L3 for pain and tenderness and I also wanted to rule out a retroperitoneal hematoma.  There’s a lot of potential options but a call to the radiologist limited it to one test with a few additional comments.  Very helpful.  But I bet if you talk to your radiologists, they’ll give you numerous examples of the wrong test or unnecessary tests being ordered on patients.  At the end of the day, there’s definitely a lot of variation in ordering patterns.

What’s the Next Step

Whether you know it or not, your hospital may be voluntarily reporting data about the AUC and CDS on these advanced imaging tests.  However, mandatory reporting will begin Jan. 1.  As ED docs, we’ll be required to consult the AUC/CDS and this will be documented in our order.  The radiologists must document that we consulted the CDS and provide very detailed documentation in their bill, including our NPI number and which CDS mechanism was consulted.  Next year will serve as a test year and will also focus on education of all providers involved.  Claims (radiology bills) will be paid regardless of the documentation and no reimbursement will be at stake.

Financial implications begin Jan. 1, 2021 and Medicare will not reimburse claims if the radiologist does not document AUC consultation.  It appears that through 2021, ordering clinicians will not be penalized if we order a test, consult AUC/CDS, and proceed with a test even though it may not be the recommended test.  However, this is likely to change in 2022 or 2023.

CMS has identified that up to 5% of providers will be considered outliers and there may be penalties for these providers, including the need to obtain pre-authorization on certain tests with Medicare patients.  At this point, it’s unclear to me whether being an outlier can impact your employability (or how long it takes to get off the outlier list) or if some you would be required to obtain pre-authorization from the ED.  That could cause significant delays in care (possibly interfering with your EMTALA obligation).  It’s also likely that the eight priority clinical areas that CMS has identified will have a role in identifying outliers.

In some ways, we’re lucky as the hospital will choose the vendor to provide the CDS program and will be responsible for integrating it into our EMRs.  Can you imagine the cost and complexity of this if you were responsible for your own privately-owned practice and facility?  We also have the benefit of being able to work closely with our radiologists, who will be working with the vendors, as this may allow for some customization of our indication choices.

What can I do now?

It’s pretty easy to dictate “chest pain and dyspnea, r/o PE” on a CT requisition.  Checking the box for the AUC and getting a warning that the head CT for your dizzy patient is not as good as the MRI is very frustrating.  At least for 2020, there are no consequences for ordering tests that aren’t recommended.  This gives us plenty of time to learn how to efficiently and appropriately play this game.  In terms of learning and understanding the program, as a first step, start to play with the AUC options that your vendor has provided to your EMR.  You will be frustrated.  However, this isn’t going away and we need to find a way to make our work flow as easy as possible.

To do that, we need to get to know the system.  I’ve already found some easy wins for my kidney stone and diverticulitis patients and I’ve also found some crazy examples where the CDS was wrong.  For example, I ordered a head CT on a new onset seizure patient. The test received an appropriateness score of 5 with a brain MRI being a 7.  I’m not looking to slow down the ED more by ordering MRIs so I contacted the radiologist who’s working on this project at our site.  I was surprised to hear back from him that the American College of Radiology, who helped write the AUC, scores a head CT for this patient a 7, even noting that this is often the study of choice in the ED.  Clearly, this is a question for the vendor.  I’m now having my docs email me examples of AUC that does not make sense.

My goal is to work with the vendor and our radiology team to eliminate the errors that we come across, like the head CT in new onset seizures. As another example, the computer recommended I order an MRI enterography rather than a CT of the abdomen and pelvis last night on an elderly male patient with abdominal distention, who was diagnosed with a high-grade obstruction, and clearly getting an MRI was not in my game plan. At the end of the day, I think we should always order what is clinically indicated in the emergency department.  And for the next year, we can team up with our radiology and IT teams to maximize the product that we’re working with.


After years of being quietly being discussed in the background, AUC and CDS is coming to the clinical area.  In a perfect world, these programs will help ensure patients get the most appropriate test, and perhaps, some docs will not order any advanced imaging on the patient.  In reality, I suspect that we’ll learn the system well enough and work with our vendors to make it easy to find our top indications that will support performing the test we want and need to care for the patient.  I expect the first few months of 2020 to be frustrating, but no reimbursement is at stake yet.  And hopefully, through a team effort with our radiologists and appropriate feedback to our docs, we’ll all be successful in 2021 and beyond when there are likely to be financial or other consequences.


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