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For Referring Providers: Preparing for Appropriate Use

The Protecting Access to Medicare Act (PAMA) of 2014 is a program designed to identify appropriate advanced imaging services for Medicare beneficiaries.

Examples of advanced imaging services include:

  • Computed tomography (CT)
  • Positron emission tomography (PET)
  • Nuclear medicine
  • Magnetic resonance imaging (MRI)

PAMA requires ordering clinicians to consult a qualified Clinical Decision Support Mechanism (CDSM), software that assists clinicians in identifying the most appropriate advanced imaging study for a patient’s specific clinical condition during the patient’s workup. The CDSM will provide the ordering professional with a determination of whether that order adheres to Appropriate Use Criteria (AUC), does not adhere, or if there is no AUC applicable to address the patient’s clinical condition. AUC are evidence-based criteria developed or endorsed by national professional medical specialty societies or other provider-led entities (PLEs). AUCs help furnishing professionals make the most patient-appropriate treatment decision for the specific clinical condition. AUC can help clinicians reduce the amount of time required to keep current with radiological advancements.

Regulatory language for this program is in 42 Code of Federal Regulations (CFR), Section 414.94, titled, “Appropriate Use Criteria for Advanced Diagnostic Imaging Services.” The program began in 2020 with an Educational and Operations Testing period. Furnishing providers are encouraged to collect AUC data at the time of scheduling advanced imaging studies and include the AUC data on claims. Required AUC data includes ordering clinician NPI, identity of the CDSM, and the AUC outcome – adheres to, does not adhere, not applicable. Clinicians retain control of the decision-making process, as AUC offers a ranking of applicable studies. The clinician chooses the study that best aligns with their patients’ condition.

On January 1, 2022, the program will impose a monetary penalty for advanced imaging studies provided without AUC consultation in applicable settings including physician offices, hospital outpatient departments (including emergency departments), ambulatory surgical centers, and any other provider-led outpatient setting. Medicare will not reimburse for professional or technical fees associated with advanced imaging studies that have not consulted a CDSM. Ordering clinicians can prepare for AUC by implementing a CDSM into their electronic medical record or accessing a web based CDSM.

Valley Health is committed to supporting community practices in the AUC transition. In the coming weeks, we will be providing additional information regarding how to prepare your practice for AUC.

Click here for information regarding the following AUC topics:

  • What are the benefits of AUC?
  • What is the cost of non-participation?
  • Who can consult the AUC?
  • What tools are available to help in the transition?

Click here for information regarding the following AUC topics:

  • Clinical Decision Support Mechanism (CDSM)
  • Tools available to help in the transition
  • Community Practice Readiness Checklist

Click here to access National Decision Support Company CareSelectTM , a free web-based CDSM tool. To go directly to the CareSelect Open Access registration page, click here.

A revised Imaging Services Referral form is available with a new Clinical Decision Support Codes data box included. This data is retrieved from the AUC at the completion of each search. View the form here.

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