Protecting Access to Medicare Act
Starting January 1, 2020 – Protecting Access to Medicare Act (PAMA) will require referring providers to consult Appropriate Use Criteria (AUC) using a Clinical Decision Support (CDS) tool when ordering advanced diagnostic imaging services – CT, MR, Nuclear Medicine and PET – for Medicare patients.
The AUC mandate, included in the Protecting Access to Medicare Act, requires all providers ordering advanced imaging exam to consult an approved CDS mechanism and relay the results of the consultation to the imaging facility.
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How does an ordering provider consult AUC?
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Ordering providers must utilize a CMS approved Clinical Decision Support tool to perform the AUC Consultation.
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What are the approved CDSMs?
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As of June 2018, the approved CDMS are:
- AIM Specialty Health ProviderPortal®*
- Applied Pathways CURION™ Platform
- Cranberry Peak ezCDS
- eviCore healthcare’s Clinical Decision Support Mechanism
- MedCurrent OrderWise™
- Medicalis Clinical Decision Support Mechanism
- National Decision Support Company CareSelect™*
National Imaging Associates RadMD - Sage Health Management Solutions Inc. RadWise®
- Stanson Health’s Stanson CDS
- Test Appropriate CDSM*
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What information is provided to the ordering provider when they consult the AUC?
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When the ordering provider consults the AUC, the system will indicate whether the clinical information provided for the exam adheres or does not adhere to the AUC.
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What do modifiers communicate and does every advanced imaging procedure code require a modifier?
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For Medicare patients, every outpatient advanced imaging procedure will require a modifier.
Modifiers communicate the following:
- If the consultation adhered to the AUC recommendation,
- If the consultation did not adhere to the AUC recommendation or;
- No consultation was required due to an exception for location (e.g., inpatient), type of patient (e.g., emergent) or ordering provider (e.g., hardship).
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Can a radiology practice/center perform this service for their referring physicians?
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No. CMS allows the provider’s employed clinical staff to perform the consultation on behalf of the ordering provider. No other entity or individual, including the radiologist may perform the AUC consultation.
TRA Medical Imaging is working hard to put the pieces in place to make this new CMS requirement as easy as possible for our referring providers. We look forward to sharing those with you soon!
For more information on Medicare and Appropriate Use Criteria, please visit: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/index.html