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, 2019, 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 clinical guidelines intended for use in decision support interactions. These guidelines form the backbone of knowledge that inform every decision support interaction. CMS defines AUC 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.” AUC are authored organizations approved by CMS as qualified Provider-Led Entities (qPLE).
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.”
Qualified Clinical Decision Support Mechanism (qCDSM)
CDSMs are the electronic portals through which a clinician accesses AUC during the patient workup. NDSC’s qCDSM, 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.
Priority Clinical Areas (PCAs)
In the CY2017 MPFS Final Rule, CMS published an initial list of Priority Clinical Areas (PCAs). PCAs are a minimum standard for AUC to be delivered by qCDSM, and will be used, in part as a baseline by CMS to measure clinicians for “Outlier Status”. Clinicians who fall into the “Outlier” category will be burned with additional Prior-Authorization requirements to place advanced imaging orders. PCAs currently cover approximately 40% of advanced imaging exams ordered under Medicare Part B and will expand with each calendar year going forward.
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.