The Protecting Access to Medicare Act

Summary

The Protecting Access to Medicare Act (PAMA) requires that physicians ordering advanced imaging exams consult Appropriate Use Criteria (AUC) through a qualified Clinical Decision Support Mechanism (qCDSM). Discover priority clinical areas and physician measurement, timing, and more related to PAMA’s AUC program. 

A comprehensive AUC consultation requirement

The Protecting Access to Medicare Act (PAMA) requires that physicians ordering advanced imaging exams consult Appropriate Use Criteria (AUC) through a qualified Clinical Decision Support Mechanism (qCDSM).

Ordering providers1 are required to consult AUC for all Medicare Part B advanced diagnostic imaging services (CT, MR, NM, PET).

Consultation is required in all applicable settings as outlined by the Centers for Medicare & Medicaid Services. These include physician offices, hospital outpatient departments (including emergency departments), ambulatory surgical centers, and independent diagnostic testing facilities.

Program Timeline

Program Start

January 1, 2020 marks the formal start of the program. Healthcare providers are required to consult a qualified CDSM when ordering advanced imaging tests.

Education and Testing Period

From 2020 until further notice, the program will operate in an “Educationand Operations Testing Period.” During this period, AUC consultation must occur across all advanced imaging, and AUC consultation information is expected to be reported on claims.

 

Payment at Risk

Previously, a Payment Penalty phase was announced for January 2023 but has since been put on hold. Per CMS: “The payment penalty phase will not begin January 1, 2023 even if the PHE for COVID-19 ends in 2022. Until further notice, the educational and operations testing period will continue. CMS is unable to forecast when the payment penalty phase will begin.” When implemented, information regarding the ordering professional’s consultation with a CDSM must be appended to the claim in order for that claim to be paid.

 

Priority clinical areas and physician measurement

CMS has outlined eight priority clinical areas (PCAs) as a baseline of clinical coverage to measure outlier physicians:

  • Coronary artery disease (suspected or diagnosed)
  • Suspected pulmonary embolism
  • Headache (traumatic and nontraumatic)
  • Hip pain
  • Low back pain
  • Shoulder pain (to include suspected rotator cuff injury)
  • Cancer of the lung (primary or metastatic, suspected or diagnosed)
  • Cervical or neck pain

Outlier calculation will be based on both AUC adherence within the PCAs and applicability of the AUC to the service. In addition to outlier calculation, the PCAs can serve as a guide to begin your CareSelect® Imaging implementation. With a focus on quality improvement opportunities, the PCAs offer a springboard to create immediate impact to address imaging overutilization.

What information is required on the claim?

CMS will accept all consultation data, as defined by the regulation, in the form of G-codes with Healthcare Common Procedure Coding System (HCPCS) modifiers. The G-code will be used to define the qCDSM ID, and CPT will be amended with HCPCS modifiers to indicate pertinent AUC consultation data.

The defined information is as follows:

  • Information about which qCDSM was consulted by the ordering professional for the service.
  • Information regarding: 
    • Whether the service ordered adheres to the applicable AUC.
    • Whether the service ordered does not adhere to such criteria.
    • Whether such criteria are not applicable to the service ordered.
    • The NPI of the ordering professional.

All claims will require CPT codes appended with the appropriate HCPCS modifier and G-codes that indicate which CDSM was consulted to qualify for payment.

Qualified CDSMs have been assigned a G-code that is specific to each mechanism. CMS has created eight new HCPCS modifiers to indicate the outcome of the AUC consultation. These modifiers fall into two categories: (1) when an AUC is consulted; or (2) when a CDSM is not consulted, for instance due to hardship.

In addition to the G-code/HCPCS modifier structure, CareSelect Imaging produces a unique consultation identifier (UCI) or decision support number (DSN). While the DSN is not required for claims purposes, it provides a valuable link between consultation and claims data. This is particularly important when the ordering and furnishing facilities are disparate domains. CareSelect retains this information for six years.

Exemptions

CMS has finalized three circumstances where ordering providers are not required to consult AUC.

These have been defined as:

  • Emergency services2
  • If the service is furnished under Medicare Part A
  • Hardship

The 2019 final rule clarifies the proposed hardship exclusion and makes the ordering provider “self-report” their exclusion from criteria; 2019 rule-making finalized a definition for “hardship” as:

  • Insufficient Internet access
  • EHR or CDSM vendor issues
  • Extreme and uncontrollable circumstances

These criteria add to the existing emergency services exclusion, where consultation is not required if it will cause undue harm to the patient.

The 2019 rule finalizes the proposal for ordering professionals experiencing a significant hardship to self-attest and include that information on the order. The furnishing professional or facility would communicate on the Medicare claim for the service by appending an HCPCS modifier identifying the ordering professional’s self-attested significant hardship category.

1 The following roles are defined as “ordering professionals” by the statute:

a)  A physician assistant, nurse practitioner, or clinical nurse specialist
b)  A certified registered nurse anesthetist
c)  A certified nurse-midwife
d)  A clinical social worker
e)  A clinical psychologist
f)  A registered dietitian or nutrition professional

2 Emergency Services have been defined in Section 1867 of the Social Security Act. The term “emergency medical condition” means:

a)    A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:

i. Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy.
ii. Serious impairment to bodily functions.
iii. Serious dysfunction of any bodily organ or part.

b)    With respect to a pregnant woman who is having contractions:

i. That there is inadequate time to affect a safe transfer to another hospital before delivery.
ii. That transfer may pose a threat to the health or safety of the woman or the unborn child..

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