Starting January 1, 2018, the Protecting Access to Medicare Act (PAMA) will require referring providers to consult appropriate use criteria (AUC) prior to ordering advanced diagnostic imaging services - CT, MR, nuclear medicine exams and PET - for Medicare patients.

Exams performed in the emergency department are included in this rule – except for the most emergent of cases (as defined under EMTALA). Inpatient exams are also exempted from this rule. Limited exceptions may be made (by HHS) for rural providers with limited internet connectivity.

Providers can access imaging AUC via stand-alone electronic clinical decision support (CDS) systems or CDS software embedded in a physician’s electronic health record (EHR). Barring Centers for Medicare and Medicaid Services (CMS) changes in the upcoming regulatory process, the ACR anticipates providers documenting that they consulted AUC by entering a provider identifier likely to be called a “decision support number (DSN)” in the exam order.

The ACR-developed CDS — ACR Select® (digital ACR Appropriateness Criteria®) — can be integrated into most common EHRs. ACR Select is expected to meet PAMA requirements. CMS will announce approved CDS systems by June 30.

No rendering provider – radiologist or otherwise — may receive Medicare payment for an advanced imaging exam if the referring provider does not verify that imaging AUC were consulted. Ordering physicians cannot shift the requirement to consult the guidelines to radiologists. Imaging providers cannot perform AUC administrative duties for referring providers.

All imaging providers may refuse Medicare referrals lacking the DSN and not be competitively disadvantaged.