What is PAMA?
Congress passed the Protecting Access to Medicare Act, commonly referred to as PAMA. In this legislation, the Centers for Medicare & Medicaid Services (CMS) released the Medicare Physician Fee Schedule (MPFS) final rule. This rule defines specific requirements that all Medicare Part B advanced imaging orders require a consultation with a qCDSM in order to be reimbursed.
Starting January 1, 2019, Medicare Part B reimbursement for advanced imaging services will require evidence of use of qualified clinical decision support mechanism. This legislation requires all providers who order advanced outpatient imaging tests for Medicare patients to consult an approved clinical decision support (CDS) system or the imaging services will not be reimbursed by Medicare. The new mandate applies to advanced outpatient medical imaging studies including CT, MR, NM, and PET.
Basic Requirements of the Mandate
• Ordering professionals must consult appropriate use criteria (AUC) for advanced outpatient imaging orders (includes CT, MR, NM, PET)
• The AUC must be developed by a qualified Provider-Led Entity (qPLE). The AUC guidelines are best-practice recommendations based on evidence.
• Ordering professionals must access AUCs through a qualified Clinical Decision Support Mechanism (CDSM) – software tool that provides a CDS consultation
• Claims generated by furnishing professionals for advanced imaging services must include specific information obtained from the CDS consultation
Are Your Reimbursements at Risk?
If you are a member of a physician’s office, hospital outpatient department, ambulatory surgical center, or any provider-led outpatient setting you will need to meet the requirements of the mandate in order to receive reimbursements for advanced imaging orders. If you do not meet this mandate, your reimbursement will be at risk for all Medicare advanced outpatient imaging procedures.
What do you need to know right now?
Radiologists should start communicating with their referring physicians to ensure that they are aware of the PAMA mandate for clinical decision support (CDS) for advanced imaging. Referring physicians should become familiar with the available CDS vendors approved by CMS. Make sure your Health IT team is working with a qualified CDSM vendor to implement the best solution for your organization.
CMS announced a list of qualified decision support mechanisms vendors that meet the provisions of the PAMA mandate.
Speed of Care offers a CMS qualified CDSM solution for radiologists and ordering providers. Contact us for a free consultation to discuss how we can help your organization meet this mandate before the January 1, 2019, deadline.