Starting January 1, 2020, 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.
ACR Select®, a digital representation of the ACR Appropriateness Criteria® for diagnostic imaging, is a module contained within CareSelect Imaging. ACR Select can be integrated into most common electronic health records (EHRs). The National Decision Support Company (NDSC), which is now owned by Change Healthcare, is a CMS approved qualified Decision Support Mechanism (DSM).
Providers can access imaging AUC via stand-alone electronic clinical decision support (CDS) systems or CDS software embedded in a physician’s EHR. The ACR anticipates providers documenting that they consulted AUC with an “unique consultation identifier” in the exam order. However, claims processing instructions will be finalized by CMS in the upcoming Medicare Physician Fee Schedule rulemaking cycle.
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. Imaging providers may refuse Medicare referrals lacking the DSN and not be competitively disadvantaged.
Exams performed in the emergency department are included in the PAMA rule — except for the most emergent of cases. Inpatient exams are also exempted. HHS may make limited exceptions for rural providers with limited internet connectivity.