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 a 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 program starts with a one-year “Educational and Operations Testing Period”. During this period, AUC consultation must occur across all advanced imaging and AUC consultation information is expected to be reported on claims, however claims will not be denied for failure to include proper AUC consultation information.
After the one-year period concludes, payment will be withheld for claims not correctly including consultation data and outlier physician calculation will begin.
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 offers the most comprehensive set of AUC available on the market. Criteria sourced from five qualified Provider-Led Entity (qPLE) medical specialty societies makes available applicable AUC for provider consultation to enable a pathway to compliant claims generation. This breadth and depth of clinical content allows health systems to identify quality and financial imperatives and foster targeted improvement programs.
Physician Measurement & Priority Clinical Areas
CMS has outlined eight Priority Clinical Areas (PCAs) as a baseline of clinical coverage to measure outlier physicians. Outlier calculation will be based on both AUC adherence within the PCAs and applicability of the AUC to the service.
In addition to outlier calculation, the PCAs can serve as a guide to begin your CareSelect Imaging implementation. With a focus on significant savings and quality improvement opportunities, the PCAs offer a springboard to create 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 Healthcare Common Procedure Coding System (HCPCS) modifiers. The G-code will be used to define the qCDSM ID and CPT will be amended with HCPCS modifiers to indicate pertinent AUC consultation data.
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, CareSelect Imaging produces a Unique Consultation Identifier (UCI) or Decision Support Number (DSN). The DSN readily connects the consultation to claim. While the DSN is not required for claims purposes, it provides a valuable link between consultation and claims data. This is particularly important when the ordering and furnishing facilities are disparate domains. CareSelect retains this information for 6 years.
A Fully Qualified Clinical Decision Support Mechanism
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 enables providers to consult required AUC for every imaging exam and that the necessary claims data 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 AUC authored by leading medical specialty societies at the point-of-care. This empowers enterprise-wide quality improvement efforts and creates a path to compliance with PAMA AUC consultation requirements.
