In addition to the listing below, be sure to check out NDSC’s PAMA Overview.
The Protecting Access to Medicare Act (PAMA)
The Protecting Access to Medicare Act of 2014 mandates that starting January 1, 2018, physicians ordering advanced diagnostic imaging exams must consult qualified, evidence-based appropriate-use criteria, namely through a Clinical Decision Support Mechanism.
The functional details of PAMA have been spelled out through an ongoing rule-making process. This process established the approval process from both Appropriate Use Criteria (AUC) and Clinical Decision Support Mechanisms (CDSM) and outlined the first set of Priority Clinical Areas (PCA).
Appropriate Use Criteria (AUC)
Appropriate Use Criteria (AUC) are guidelines created or endorsed by qPLE intended for use in decision support interactions. These guidelines form the backbone of knowledge that inform every decision support interaction. “AUC are defined as criteria that are evidence-based (to the extent feasible) and assist professionals who order and furnish applicable imaging services to make the most appropriate treatment decisions for a specific clinical condition.”
Qualified Provider Led Entity (qPLE)
A qualified Provider-led entity (qPLE) is responsible for the creation of sets of AUC for use in CDS interactions. Each organization approved to create or endorse AUC follows strict guidelines and rules for criteria authoring. CMS defines a qPLE as a “national professional medical specialty society or other organization that is comprised primarily of providers or practitioners who, either within the organization or outside of the organization, predominantly provide direct patient care.”
Examples of AUC published by qPLE include criteria published by National Medical Specialty Societies such as ACR, ACC, NCCN and SNMMI. Individual sites may also apply to be qualified such that they can publish and use their own AUC to manage imaging decisions.
Clinical Decision Support Mechanism (CDSM)
“CDSMs are the electronic portals through which clinicians would access the AUC during the patient workup.”3 NDSC’s CDSM, CareSelect Imaging™, automatically incorporates information such as specific patient characteristics, laboratory results, and lists of co-morbid diseases from Electronic Health Records (EHRs) and other sources. With a fully embedded CDS platform, practitioners interact directly with the CDSM through their primary user interface, minimizing interruption to the clinical workflow.
The mandate specifies that caregivers must consult a qCDSM for every Medicare Part B FFS advanced imaging (CT, MR, NM. PET) placed in the outpatient setting (detail examples). For every furnished service, each claim must contain evidence of the qCDSM consultation to be payable.
Priority Clinical Areas (PCA)
CMS has defined eight Priority Clinical Areas that will be used as a tool to measure outlier ordering professionals. The PCA represent a baseline for AUC coverage and will expand year over year and reduced AUC coverage within a CDSM will not reduce the requirement to consult and document a reason for exam for every advanced imaging order.
The final list of priority clinical areas includes 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), and cervical or neck pain.
Ordering Provider (OP)
An ordering provider is the individual who orders an item or service (e.g., laboratory diagnostic tests or imaging services) that will be furnished and billed by another provider or supplier (e.g., laboratory, imaging center).
Furnishing Provider (FP)
A furnishing provider is the organization or health system that furnishes and bills Medicare for the ordered service provided to the beneficiary.
Decision Support Number (DSN)
Every CDSM consultation must record the physicians NPI and then assign a unique Decision Support Number (DSN). This DSN serves as the “unique consultation identifier” and provides a reference to details of the CDSM consultation including adherence, and applicability of the selected service with the AUC. It contains all required data elements for a claim. CMS will define how the DSN will be used in the claims process in next year’s rule-making cycle.