Bracing for Medicare’s Appropriate Imaging Rule

Acronyms to know:
PAMA   Protecting Access to Medicare Act

CDSM   Clinical Decision Support Mechanism

AUC      Appropriate Use Criteria

ACR      American College of Radiology

CMS     Centers for Medicare and Medicaid Services

PAMA is a CMS clinical decision software that processes every CT, MRI, Nuclear Medicine and PET order performed.  PAMA assigns criteria for appropriateness for these procedures based on its decision support algorithm.  The analysis will determine if the AUC falls into one of three categories; “appropriate”, “maybe appropriate” or “rarely appropriate”.  Physicians and facilities that demonstrate patterns of non-compliant ordering may be subject to required preauthorization.  Specific penalties have not been released by CMS.

PAMA was signed into law back in 2014 but was delayed several times due to implementation challenges.  More than 24 medical societies have asked CMS to loosen and delay the requirements, but the roll out date is set for January 1, 2020.  The ACR has not asked CMS to delay the policy.  The first year, there is a grace period with no penalties for incorrect reporting.  On January 1, 2021 Medicare will begin rejecting payment for non-compliant reporting.

CMS has identified eight priority areas where physicians order too many inappropriate imaging procedures.  They are: coronary artery disease, suspected pulmonary embolism, headache, hip pain, low back pain, shoulder pain, lung cancer and cervical/neck pain.  Providers will be required to use AUC codes appropriate for each exam, which may be interpreted differently from facility to facility.  Slightly differing combinations of AUC codes may determine appropriateness making it even more frustrating for ordering physicians.

Providers are concerned that compliance will be costly and difficult to correlate across different EMRs and for providers that have systems that don’t integrate with the imaging facility.  The task of learning AUC criteria will take time and will surely have a fair amount of hiccups.  Another concern is that providers might refer patients to specialist to avoid dealing with the CDSM, thus driving cost up even further.  John Mongan, M.D., Ph.D., of the University of California Medical Center summed it up by saying, “This program is, to my knowledge, unique in the history of health informatics in creating a nationwide regulatory requirement for implementation of something…comprehensive imaging clinical decision support…that no one has yet done successfully.”


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