Clinical Decision Support

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 “unique consultation identifier” 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.

What You Need to Know

  1. For a brief introduction to this topic, read Clinical Decision Support for Appropriate Imaging – How Did We Get Here? and for further details, read Background and Frequently Asked Questions about Protecting Access to Medicare Act of 2014
  2. Read the following ACR statements:
  3. Read these Imaging 3.0 case studies for best practices on supporting CDS for appropriate imaging and for inspiration from other radiology practices that have had pioneering success in this area:

A Symptomatic Approach - A Wisconsin radiologist has developed a symptom-based program to help referring clinicians and their staffs order appropriate imaging exams.

Homing in on Quality - Radiologists in rural western North Carolina are strengthening their relationships with local physicians and reducing inappropriate imaging via R-SCAN™.

Integrity in Imaging - Radiologists at Beth Israel Deaconess Medical Center are working with referring physicians to reduce the uncritical use of inpatient imaging.

Order and Unity - Texas radiologists create a radiology utilization conference to educate nonradiology clinical staff on appropriate image ordering procedures.

Quality’s Wider Scope - A co-management agreement helps one North Carolina radiology practice achieve its quality goals.

Reinventing Curbside Consults - A hospital integrates radiology eConsults into its EMR to make it faster and easier for PCPs to get answers about imaging and improve patient care.

Shaping Change from Within - Using R-SCAN™ as a transformation tool, a radiology group reduced inappropriate follow-up imaging by nearly 55 percent for patients with ovarian masses.

Standing Out from the Crowd - Indiana radiologists develop an imaging consult service and a targeted messaging campaign as part of a value-based imaging program.

Teaching Imaging Appropriateness - A simulation-based educational program increases medical students’ abilities to identify appropriate imaging.

The Benefits of Collaboration - Radiologists and emergency department physicians partner on an R-SCAN™ project — successfully reducing unnecessary imaging by 52 percent.

Watch Videos

These four videos from a 2016 event on CDS for Appropriate Imaging total about 70 minutes.

What You Need to Do

  1. Use CareSelect Imaging
    ACR Select, a digital representation of the ACR Appropriateness Criteria for diagnostic imaging, is a module contained within CareSelect Imaging. Educate referring providers on ACR Select, which meets PAMA requirements. ACR Select may be integrated with all major computerized ordering/EHR systems and is freely available to all providers via the ACR Select web portal. See other qualified Decision Support Mechanisms approved by CMS.
  2. Pursue MACRA credit for your implementation   
    By promoting CDS/AUC use, radiologists can position themselves as a resource to hospital/health system administrators as medicine transitions from volume- to value-based care.

    Your practice’s use of a qualified Clinical Decision Support Mechanism (qCDSM) can help you receive credit towards to the Advancing Care Performance Category.
  3. Participate in R-SCAN™ 
    By taking part in the Radiology Support, Communication and Alignment Network with your referring providers, you can become familiar with CDS/AUC. You also get CME Credit and ABR MOC Part 4 Credit. R-SCAN is CMS-funded and is administered by ACR. Learn more about the Choosing Wisely topics incorporated into R-SCAN  in this JACR series.

  4. Use Radiology-TEACHES in teaching programs for referring clinicians
    If you are affiliated with a teaching program for referring clinicians (DOs, MDs, PAs or NPs), encourage them to participate in the ACR’s Radiology-TEACHES program which provides training on ordering appropriate imaging.

Journal Articles

Related Articles

Clinical Decision Support

ACR Select®, a digital representation of the ACR Appropriateness Criteria® for diagnostic imaging, is a module contained within CareSelect Imaging.

ACR Select is ready to incorporate into computerized ordering and EHR systems to guide providers when ordering medical imaging scans.

Get ACR Select

Radiology Support Communication and Alignment Network

Collaborate with radiologists and referring clinicians to improve imaging appropriateness based on Choosing Wisely topics.

Participate in R-SCAN