The contents of this document are intended to convey general information only and not to provide legal advice or opinions.
The Protecting Access to Medicare Act (PAMA)
The Protecting Access to Medicare Act requires that physicians ordering advanced imaging exams consult Appropriate Use Criteria (AUC) through a qualified Clinical Decision Support Mechanism (qCDSM).
January 1, 2020 marks the formal start of the program, where healthcare providers must consult qualified CDSM when ordering advanced imaging tests. Under the program, consultations must occur across all advanced imaging and evidence of consultation must be included on the claim. The consultation requirement applies to all Medicare Part B Advanced Diagnostic Imaging Services (CT, MR, NM, PET) across multiple care settings including outpatient and emergency departments.
The first year of the program is defined as an “Educational and Operational Testing Period”. During this year, consultations must occur, and providers must submit evidence of consultation for all imaging exams. During testing, payment will not be withheld for incorrectly formed claims. After the one-year period concludes and the formal program starts, payment will be withheld for incorrectly formatted claims.
A Comprehensive Requirement
Ordering providers are required to consult AUC for all Medicare Part B Advanced Diagnostic Imaging Services (CT, MR, NM, PET).
Consultation is required in all applicable settings as outlined by CMS. These include physician offices, hospital outpatient departments (including emergency departments), ambulatory surgical centers, and independent diagnostic testing facilities.
CareSelect Imaging offer the most comprehensive set of AUC available on the market. With criteria sources from five qPLE medical specialty societies, CareSelect Imaging ensures the availability of applicable AUC for provider consultation and compliant claims generation. The breadth and depth of clinical content also allows health systems to identify quality and financial imperatives and foster targeted improvement programs.
Physician Measurement & Priority Clinical Areas
CMS has outlined six Priority Clinical Areas (PCAs) as a baseline of clinical coverage to measure outlier physicians. Outliers will be based on AUC adherence within the PCAs and applicability of the AUC to the service.
In addition to outlier calculation, the PCAs serve as a good guide to begin your CareSelect Imaging implementation. With a focus on significant savings and quality improvement opportunities, the PCAs offer a springboard to create meaningful, immediate impact to address imaging over-utilization.
- Coronary artery disease (suspected or diagnosed)
- Suspected pulmonary embolism
- Headache (traumatic and non-traumatic)
- Hip pain
- Low back pain
- Shoulder pain (to include suspected rotator cuff injury)
- Cancer of the lung (primary or metastatic, suspected or diagnosed)
- Cervical or neck pain
Claims & Reporting
CMS will accept all consultation data, as defined by the regulation, in the form of G-Codes with HCPS modifiers. The defined information is as follows:
- Information about which qCDSM was consulted by the ordering professional for the service.
- Information regarding—
- whether the service ordered adheres to the applicable appropriate use criteria;
- whether the service ordered does not adhere to such criteria; or
- whether such criteria is not applicable to the service ordered.
- The NPI of the ordering professional
In addition, the qCDSM must produce a Unique Consultation Identifier or Decision Support Number (DSN). This DSN readily connects the consultation to claim, particularly when the ordering and furnishing facilities are disparate domains. Although the proposed rule suggests that the DSN is not required for claims purposes, the DSN is required to connect the consultation and claims data. This ensures protection against future audit, as the qCDSM must retain this information for 6 years.
A Fully Qualified Clinical Decision Support Mechanism
CareSelect, the technology platform behind CareSelect Imaging, has been fully qualified by CMS for use to comply with the AUC provisions of PAMA. While this qualification signifies that our CareSelect solutions meets the minimum technical and AUC coverage requirements as outlined by CMS, we wanted to do more.
CareSelect Imaging is built on the most comprehensive set of published AUC covering advanced imaging, ACR Select™. In addition, CareSelect Imaging delivers a comprehensive set of structured indications and AUC from five qPLE, including all qualified medical specialty society AUC, rationalized into a single delivery platform.
The platform’s comprehensive clinical coverage ensures that providers can consult required AUC for every imaging exam and that a payable claim is always generated.
Connect Compliance, Quality & Savings to Clinical Decision Support
CareSelect is the preferred qCDSM of all major EHR vendors. Our CareSelect Imaging solution delivers Appropriate Use Criteria (AUC) authored by leading medical specialty societies at the point-of-care. This empowers enterprise-wide quality improvement efforts and ensures compliance with PAMA AUC consultation requirements.