Clinical Decision Support – Are you Ready?

The Protecting Access to Medicare Act of 2014 (PAMA), mandates all referring physicians are required to consult appropriate use criteria (AUC) prior to ordering advanced diagnostic imaging services for Medicare patients, performed in specifically identified settings, starting on January 1, 2018.

PAMA defines advanced diagnostic imaging services as:

  • CT
  • MR
  • Nuclear medicine
  • PET

PAMA defines the settings (with expected place of service codes) where referring providers will be required to consult appropriate use criteria (AUC) prior to ordering advanced diagnostic imaging services for Medicare patients as:

  • Physician’s office (POS 11)
  • Hospital-based outpatient department (including the ED) (POS 22)
  • Ambulatory surgical center (POS 24)
  • Any other provider-led outpatient setting determined by the Secretary of Health and Human Services (POS 19)

Inpatient exams as well as exams conducted under emergent situations will be exempt from consulting and reporting requirements under PAMA.  CMS acknowledges that most emergent situations will occur in the ED, but could occur in other healthcare settings as well.  The rule states “to meet the exception for an emergency medical condition, the clinician only needs to determine that the medical condition manifests itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in: placing the health of the individual (or a woman’s unborn child) in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part.”

As previously stated, effective January 1, 2018 all referring providers who order covered studies in the settings listed above will be required to consult appropriate use criteria (AUC) prior to ordering.  Referring providers will be able to consult AUC through a Clinical Decision Support Mechanism (CDSM).  CMS will release the approved list of CDSM vendors in June 2017.

Currently, CMS is indicating that providers must report three items on claims to receive full reimbursement:

  1. The CDSM consulted
  2. Whether the order adheres to AUC, does no adhere to AUC, or is not applicable
  3. National provider identification (NPI) number of the ordering physician

CMS will also designate certain referrers as outliers, using a set of eight procedures making up about 40% of all Medicare imaging.  Up to five percent of providers will be branded as outliers and will be required to obtain preauthorization for Medicare patients.

As always, ADVOCATE will keep you up to date on this and all issues impacting radiology as they become available.

Regards,
Lauren Sloan, MHA, RD, LD
Director of Regulatory Affairs