Will your Medicare reimbursement survive CMS’s New CDSM mandate?


 As a late addition to the “Protecting Entry to Medicare Act” (PAMA) handed by Congress in 2014, the Centers for Medicare and Medicaid Providers (CMS) has initiated the Correct Use Standards (AUC) Program, which contains the Scientific Choice Assistance System (CDSM). The mandate demands purchasing vendors to consult an AUC software plan when buying highly developed imaging assessments and then issuing a certification of compliance to the rendering company so that they will be reimbursed by Medicare.

The AUC application was made to aid diagnosing doctors when they buy highly developed imaging assessments, but, counterintuitively, impacts the rendering physician’s reimbursement if they never receive the certification of compliance right from the purchasing service provider. Eighteen months into the two-yr instruction period and several ordering suppliers are unaware of the new mandate that normally takes impact commencing January 1, 2022.

For suppliers billing Medicare Section B, the effects on income could be considerable. Radiology, cardiology, and orthopedic techniques, as nicely as outpatient medical center services and imaging centers, will be reliant on buying vendors or stand to drop the income outright. The only exceptions will be for inpatient providers (billing for Medicare Component A), unexpected emergency people, and buying doctors with significant hardship, these as rural destinations or deficiency of available world-wide-web.

CDSM — what is it and how will it affect Medicare reimbursement?

For referring companies that purchase an innovative imaging examination, like MRIs and CTs, the new mandate involves them to talk to CMS-authorised CDSM application with AUC to determine if the exam is warranted. If so, the computer software generates and forwards a certification of compliance and forwards it to the suitable rendering supplier.

The certificate is then held in the patient’s healthcare report with results codified on the outgoing imaging claim to Medicare. This mandate produces a special predicament where the purchasing provider is dependable for the session, but the rendering company is the a person with reimbursement at threat.

What tests involve an AUC session with the new mandate?

The next innovative imaging exams have to have CDSM:

  • computed tomography (CT)
  • magnetic resonance imaging (MRI)
  • nuclear medicine, and
  • positron emission tomography (PET)

When purchasing sophisticated imaging checks for Medicare Aspect B individuals, buying suppliers will be expected to talk to with a CMS-competent CDSM. Then the final results of the AUC consultation will be forwarded to the rendering company for inclusion on the Medicare reimbursement assert.

Does the new mandate have approved CDSM computer software or conditions?

Of course, CMS hand-selected a group of sellers to acquire their very own proprietary software program to take care of the AUC requirements and CDSM process. For just about every authorised vendor, CMS worked with the AMA to problem organization-particular G Codes for assert reimbursement needs.

Will existing records methods be ready to combine with the new CDSM digital portal?

Yes, specialties these kinds of as radiology, orthopedics, oncology, cardiology, snooze medication, and other folks will need CMS-capable CDSM software package developed precisely for use with qualified service provider direct entities (qPLEs) to assist in the analysis assistance. This CDSM Computer software will integrate seamlessly with current EMR/EHR/RIS techniques.

Are all primary and specialty providers impacted by this?

Any service provider who works by using state-of-the-art imaging technological know-how to diagnose Medicare Aspect B sufferers ought to be in compliance with CDSM — which includes main care, radiology, cardiology, oncology, rest medicine, pain medicine, and orthopedics, amongst other specialties.

The only exclusions are for emergencies, inpatients necessitating testing (Medicare Component A), and for suppliers that demonstrate a hardship such as not acquiring entry to dependable web products and services. There are new HCPCS Modifiers for every of these predicaments. Rendering suppliers will want to use the appropriate modifier on each claim to state their case.

For illustration, the modifier “MA” is utilized for any suspected or confirmed unexpected emergency the place time didn’t let for the use of the CDSM.

What comes about if a Certification of Compliance isn’t forwarded to the rendering supplier?

Rendering providers will be necessary to comply with the CDSM mandate or risk the reduction of income commencing January 1, 2022. Although the CMS is deciding on to aim on outreach and training at this time, there are options to watch and initiate implications for those ordering vendors that resist complying with the mandate in the upcoming.

What does the furnishing provider’s superior imaging claim want to contain to demonstrate receipt of the compliance certificate?

These three values will be required on every assert:

  1. CPT G-codes that detail which CMS-accepted CDSM software program seller was used,
  2. Very similar to prior authorizations, there will be a exclusive consultation identifier amount that will offer proof of a consult with, and
  3. HCPCS modifier that will point out whether the referral meets qPLE conditions or not. If the standards suggest that the state-of-the-art imaging examination is outside the house the scope of AUC, the ordering service provider can proceed with the examination but has to point out on the Certification of Compliance that their selection is outside the house CMS recommendations.

Will screening be reimbursed even if it does not adhere to the AUC?

Of course, there is an HCPCS code that denotes the AUC was consulted. Rendering providers will be reimbursed for the procedure and the ordering supplier might face financial repercussions in the potential if there is a defined pattern of non-compliance (as however undetermined).

Are doctors organized for the new CDSM mandate?

No matter whether unaware of the new mandate or unwilling to take part, lots of vendors, both buying and rendering are basically not ready for January 2022. In accordance to the American College or university of Radiology (ACR), it has fallen to rendering vendors to give training by way of outreach and expert schooling for their ordering doctor foundation.

How can furnishing vendors help buying suppliers by way of this adjust?

By way of highly developed automation and equipment finding out, there is software that will simplicity the load for both equally purchasing and furnishing suppliers. The finest possibility is a CDSM Alternative from an approved vendor that gives the capacity for furnishing providers to send out a hyperlink to generate a CDSM talk to to the ordering provider’s email. Then the buying service provider (or their designee) can deliver the certificate and return a copy to the rendering supplier in genuine-time.


Regardless of the significant details campaign spearheaded by CMS, quite a few vendors are unaware of CDSM and the new CMS mandate. Proactive radiology teams and hospital-supported outpatient programs have been furnishing outreach applications to educate purchasing medical professionals in the use and importance of the new CDSM computer software choices.

Nevertheless, in the long run, CMS could require non-compliant providers with a substantial charge of non-adherent processes to get extra approval, this sort of as prior authorizations, or facial area financial chance.

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