Important information regarding PAMA and outpatient radiology services

By Don Klingen, MD, CMIO

Some of you may have already received communications from other regional health systems regarding the PAMA act and what’s needed to order outpatient radiology studies.

The Protecting Access to Medicare Act of 2014 (PAMA) introduced a new regulation called the Medicare Appropriate Use Criteria Program (AUC). Effective January 1, 2020, ordering professionals must consult a qualified Clinical Decision Support Mechanism (qCDSM) when ordering advanced diagnostic imaging (CT, MRI, NM, PET) for Medicare Part B beneficiaries.

This year is an educational and testing year, with payment denials to begin promptly in 2021. We are beginning our education and messaging work now to prepare folks for 2021.

Providers who fail to consult a qCDSM, or those who frequently elect to order imaging studies that are considered “not appropriate,” will be evaluated by the Centers for Medicare & Medicaid Services (CMS). Providers who rank in the bottom 5% of ordering professionals will be subject to prior authorization for these services.

Main Line Health has already integrated radiology decision support (ACR select) with the Epic medical record system in our Emergency Rooms and Ambulatory environments for this purpose. We will be sending out a separate communication to those clinicians to give more details on what they need to do.

For independent providers the expectation is that your EMR software would be able to provide the needed decision support codes.

To see if your EMR supports decision support or to find out where to go to access online resources if your EMR does not- see information in the attached FAQ.

This is the first of many communications you will see on this act. Our intent this year is to make folks aware of the requirement and provide education.

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