HPC Corner: Are You PAMA Prepared?…What the H?

Author: Jacqueline A Bello MD, FACR ASNR past President, Chair, ACR Commission on Q&S

The History:

The Protecting Access to Medicare Act (PAMA), of 2014, requires consultation of Appropriate Use Criteria (AUC) in ordering advanced imaging studies (CT, MRI, Nuclear Medicine/PET) for outpatient Medicare beneficiaries in order for reimbursement by CMS to occur.

The AUC must be provided through a CMS approved Clinical Decision Support Mechanism (CDSM).

PAMA implementation, initially set for 1/1/17, was delayed, until recently included by CMS in the Medicare Physician Fee Schedule (MPFS) final Rule for CY 2019.

The Horizon:

Beginning January 1, 2020, ordering clinicians must consult AUC in ordering advanced imaging studies on these patients.

  • The MPFS final rule expanded the PAMA applicable payment settings from physician offices, hospital outpatients and ambulatory surgical centers to also include independent diagnostic testing facilities.
  • Consultation by ordering professionals may be performed by clinical staff under the direction of the ordering professional.
  • Claims-based reporting will involve providing CDSM specific codes and modifiers documenting AUC consultation.
  • CMS plans to release coding guidelines and collect feedback to ease implementation!

CMS has designated 2020-2021 as an Educational and Operations testing period, during which payment will not be at risk for non-compliance.

However, beginning January, 2021, payment WILL be at risk!

Allowed exemptions include:

  • Insufficient internet access
  • EHR or CDS mechanism vendor issues
  • Extreme/uncontrollable circumstances
  • Inpatient and EMTALA services

Outliers (non-compliant ordering clinicians) identified in CYs 2022, 2023 will become subject to prior authorization pathways.

The Hype:

Clinical Decision Support (CDS) is NOT prior-authorization!!!!! In fact, there is NO “Hard Stop” to bypassing the AUC recommendation.

Unlike prior-authorization, there is no FTE sitting (endlessly) on the phone; CDS occurs at the point of care, offering immediate feedback on imaging appropriateness to the ordering professional.

The Hope:

CDS offers an educational tool for physicians and patients, with potential to increase patient engagement in understanding their care pathway.

CDSMs can be seamlessly integrated into market share EHR order entry systems.

Ordering physicians (but not imaging-providing physicians) can receive high level credit in the Merit-based Incentive Payment System (MIPS) Performance Category of “Improvement Activities” under the value-based Quality Payment Program (QPP) legislated by MACRA.

Protects patients from unnecessary imaging / radiation.

Promotes care coordination!

The Help:

Webinar: “PAMA AUC Deadline is Firm—Prepare Now for 2020!”


More History (and Disclosure):

ACR has been developing Appropriateness Criteria (AC) for diagnostic imaging since 1993 and is one provider of AUC to the National Decision Support Company, developers of Care Select™, a CMS approved “Qualified Clinical Decision Support Mechanism”.

Thanks to the many ASNR members who lead/contribute to the ACR Neuroradiology AC panels that create the AC!

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