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Are you ready for CMS Clinical Decision Support Mechanisms, effective January 2020?

Xoran has your back—we have the latest information on CMS, all in one place!

CMS (Centers of Medicare and Medicaid Services) has announced that effective Jan. 1, 2020, Medicare Administrative Contractors (MACs) should accept the Appropriate Use Criteria (AUC) related to HCPCS (Healthcare Common Procedure Coding System) modifiers on claims.

Background from CMS

The Protecting Access to Medicare Act (PAMA) of 2014, Section 218(b), established a new program to increase the rate of appropriate advance diagnostic imaging services furnished to Medicare beneficiaries.

Yes, Computed Tomography (CT), does fall into the category of advanced imaging services.

What this means for your ENT practice

What this means is that, effective Jan. 1, 2020, Medicare and Medicaid patients must essentially be prior authorized for CT imaging through what Medicare calls “Clinical Decision Support Mechanisms,” or CDSM. For a list of Qualified CDSM as of June 2019, click here.

The CMS Medicare Learning Network states, “Under this program, when an advanced imaging service is offered for a Medicare beneficiary, the ordering professional will be required to consult a qualified Clinical Decision Support Mechanism (CDSM).”


There are exceptions to consulting CDSMs, which include:

  • Ordering professional has a significant hardship
  • Patient has an emergency medical condition
  • Inpatient has an applicable imaging service, and payment is made under Medicare Part A

Voluntary Testing Period

Effective on January 1, 2020 (the start of the AUC program Educational and Operations Testing Period), CMS should accept the Appropriate Use Criteria (AUC) related HCPCS modifiers on claims.

Voluntary participation was established for this program from July 1, 2018, through December 31, 2019. Medicare Learning Network article, MM 10481 discusses the voluntary participation period. This contains information related to the Educational and Operations Testing Period which is expected to last for one year (January 1, 2020 – December 31, 2020). Full program implementation is expected January 1, 2021. At that time, information regarding the ordering professional’s consultation with CDSM, or exception to such consultation, must be appended to the furnishing professional’s claim in order for that claim to be paid.

Xoran is here to help! Call 800-70-XORAN or email for more help or information on implementing MiniCAT point-of-care CT into your practice. As always, please consult the Medicare guides for making the best decisions for your ENT practice.

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