there's no way for a qCDSM to reply with the CMS allowed exceptions explaining the absence of one of the three allowed `pama-rating`

[isaacvetter]

CMS specifies permitted error scenarios in which it's permitted to not have an appropriateness score, they are, specified here, but summarized below:

Exceptions. Consulting and reporting requirements are not required for orders for applicable imaging services made by ordering professionals under the following circumstances: 
1. Emergency services when provided to individuals with emergency medical conditions as defined in section 1867(e)(1) of the Act. 
2. For an inpatient and for which payment is made under Medicare Part A. 
3. Significant hardships for ordering professionals who experience any of the following: 
            (i)Insufficient internet access. 
            (ii)EHR or CDSM vendor issues. 
            (iii)Extreme and uncontrollable circumstances.

Of these exceptions, these would need to be returned by the qCDSM to the CPOE:

1. Internet Access Issues
2. Technical Issue; EHR or qCDSM
3. Extreme/Uncontrollable Circumstances
4. and maybe Emergency Medical Condition

Could we add a new extension enabling the qCDSM to return one of these exceptions? I think it would only ever make sense for a qCDSM to return an exception if they were unable to assign an appropriateness rating. Perhaps a fourth "meta-" appropriateness rating?

[cfeltner]

From our practical experience with this IG, these exceptions have all been handled on the EHR side. In the cases when these exceptions are occurring the EHR is not able to successfully interact with the qCDSM and so the qCDSM is not able to returned a coded exception. The "emergency services" and "extreme and uncontrollable circumstances" would likely need to be discerned from the ordering clinician and the qCDSM is not even called in these cases due to time and urgency.