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CO: Hospital Turned Down Recommendation to Drop Tests From CDSM Because of AUC Concerns

A hospital compliance officer is uneasy about what he said is a recommendation by its clinical decision support mechanism (CDSM) vendor for CMS’s appropriate use criteria (AUC) requirement. He said the vendor, CareSelect, recommended removing 163 advanced imaging tests from the CDSM, which physicians use to check whether the tests are appropriate, and reporting the MG modifier on claims to explain why the imaging tests skipped the CDSM.

“What CareSelect is saying is for these 163 studies, the provider will bypass the CDSM, and we would still put the MG modifier on the claim,” the compliance officer, who preferred not to be identified, contended. “In other words, the provider would not consult the CDSM as is required by CMS.” That isn’t a good idea, according to the compliance officer, who’s worried about the compliance implications. Hospitals may get paid, but if they’re audited by CMS, there will be a problem if they “can’t produce a confirmation the provider consulted the CDSM.” The MG modifier indicates “the order for this service does not have appropriate use criteria in the clinical decision support mechanism consulted by the ordering professional.”[1]

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