What do radiologists need to know about PAMA and the approaching CDS mandate?
First of all, radiologists need to know that the PAMA mandates are real and the deadlines are rapidly approaching. Starting Jan. 1, 2020, PAMA requires referring providers to consult appropriate use criteria (AUC) prior to ordering advanced diagnostic imaging services — CT, MR, Nuclear Medicine and PET — for Medicare patients. An AUC consult must be documented via a CMS-qualified clinical decision support mechanism (qCDSM).
When will radiologists be impacted financially if that AUC consultation does not happen?
The AUC consultation requirement will start with a 12-month educational and operations testing period, which runs Jan. 1, 2020 – Dec. 31, 2020. During the period, professionals must participate in the program and make an effort to use the AUC claims process, but payment is not at risk if there are shortcomings or mistakes. Beginning Jan. 1, 2021, rendering professionals’ technical and professional component reimbursement could be denied for failure to verify that the AUC process was satisfactorily used.
Do referring providers have any skin in the game when it comes to being denied reimbursements?
Ironically enough, the ordering clinician does not have any penalty. It's solely on the radiologist and whoever owns the imaging scanner. That’s the paradox with this mandate: Only the “rendering providers” will potentially be denied reimbursement for a scan without a documented AUC consult. So, the onus is squarely on radiologists to take a leadership role in ensuring CDS is implemented and the AUC consultation process is operationalized in their environment well before the 2021 deadline — when payments will be impacted. Not only do we have the knowledge and expertise about appropriate imaging, we have a financial incentive to ensure the right scans are ordered, with the proper coding of consult via CDS, so that we can be paid. According to CMS, eventually providers who routinely order inappropriate exams could be required to obtain preauthorization for a study.
Beyond the financial implications, why else should radiologists take a leadership role in implementing CDS in their practices?
Increasingly, it is imperative for radiologists to demonstrate their value in patient care and their roles in image ordering using the most appropriate criteria for the patient’s condition. One of the areas where we add value (besides generating a radiological report) is ensuring that the patient is obtaining the correct study for a given problem. So shepherding CDS implementation is one way that we can add value to patient care and make it easier for our referring colleagues to order the right study. Until recently, radiology’s AUC has been sitting in huge binders packed with paper that were difficult to access at the point of care. It is now much more accessible to the clinician through CDS and the EMR, so it’s a convenient way to provide value for the clinician.
What are some actions radiologists can take now to get started implementing CDS in their own practices?
Based on our experience implementing CDS at Einstein, here are five key steps that I recommend to every radiology department or practice:
Ryan K. Lee, MD, MBA, is Clinical Associate Professor at the Sydney Kimmel College at Thomas Jefferson University. He is the Section Chief of Neuroradiology in the Einstein Healthcare Network and serves as Vice Chair of Quality and Safety and Magnetic Resonance Medical Director in the Department of Radiology. His areas of expertise include radiation management in imaging, radiology CDS, MRI safety and increasingly, artificial intelligence. With practical experience in the implementation of radiology CDS, he has given numerous lectures regarding its benefits. He is also well versed in the economics of health care, including within the realm of radiology, and serves as the Alternate RUC Advisor for the American Society of Neuroradiology.
Dr. Lee is a member of the ACR Appropriateness Criteria® Neurological Imaging Subcommittee, ACR MACRA committee, ACR Economics Subcommittee on Neuroradiology, and the Quality and Safety Committee of the ACR Commission on General, Small, Emergency and/or Rural Practice.