January 15, 2020

CMS Issues Additional Guidance for PAMA Appropriate Use Criteria

The Centers for Medicare and Medicaid Services (CMS) recently published an institutional claims processing guidance for the Protecting Access to Medicare Act (PAMA) appropriate use criteria (AUC) mandate as it pertains to advanced diagnostic imaging services billed under Medicare Part B.

The Special Edition MLN Matters article instructs providers of advanced diagnostic imaging services in the hospital outpatient setting to report the ordering professional’s National Provider Identifier using the K3 segment of the claim form. The article provides detailed instructions with examples of how to report the information under various circumstances (e.g., multiple imaging studies ordered by different providers).

CMS also reminds providers that the “educational and operations testing period” for the AUC program began on Jan. 1, 2020. Although no penalties will be imposed for failure to report AUC consultation information or incorrectly reporting the information during the testing period, CMS encourages providers to participate in the testing period because it allows them and the Agency to practice submitting and receiving the information prior to the application of payment risk.

For questions about the PAMA mandate, please contact the American College of Radiology at PAMA-AUC@acr.org.