In the recent proposed rule for year two of The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the Centers for Medicare and Medicaid Services (CMS) have introduced a surprising twist – linking the Protecting Access to Medicare Act (PAMA) to MACRA.
Tucked away on page 178 of the proposed rule is a new improvement activity linked to the Advancing Care Performance Category. This improvement activity allows organizations who have implemented a qualified Clinical Decision Support Mechanism (qCDSM) to receive credit in this category:
A MIPS eligible clinician would attest that they are consulting specified applicable appropriate use criteria (AUC) through a qualified clinical decision support mechanism for all advanced diagnostic imaging services ordered. This activity is for clinicians that are early adopters of the Medicare AUC program (e.g., 2018 performance year) and for clinicians that begin the program in future years as will be required by CFR §414.94 (authorized by the Protecting Access to Medicare Act of 2014). Qualified mechanisms will be able to provide a report to the ordering clinician that can be used to assess patterns of image-ordering and improve upon those patterns to ensure that patients are receiving the most appropriate imaging for their individual condition.
This development provides some tantalizing useful and important insight into the PAMA regulatory process:
- Providers must attest to consulting the qCDSM across all advanced imaging. We recognize that CMS has yet to publish the anticipated 3rd MPFS proposed rule; however this should clear up any mystery about limiting consultations to just the 8 Priority Clinical Areas (PCA). NDSC’s interpretation has always been that all advanced imaging orders require a consultation of applicable AUC, not just the PCAs.
- Our interpretation is that the timing for PAMA will now align with the first MACRA payment adjustment. CMS is rewarding providers who have or are currently adopting AUC based on CMS’ guidance that starting Jan 1 2018, claims for Medicare Part B advanced imaging services require evidence of a qCDSM consultation.
In short, the country’s largest payer now requires consultation with a qCDSM across all advanced imaging services. This is certain to have implications for traditional utilization management approaches that rely on prior authorization through third parties.
Useful Links: MACRA Proposed Rule Fact Sheet
Imaging orders flow to furnishing sites in a variety of ways. Too often, these orders are “sent” via the patient, who leaves the caregivers office with a piece of paper. We get a lot of questions about how to manage walking paper, including orders via email and the trusty fax machine, with consideration of the new PAMA requirements. Here is our solution.
The solution starts with the ordering provider asking a clear, clinical question to answer through imaging that the furnishing imaging provider can understand. When linked to a DSN, that indication can flow from order all the way through billing.