Protecting Access to Medicare Act (PAMA)

Provider Portal User Guide

Helpful information for navigating NHRMC's CDSM Provider Portal

Stanson Portal User Guide 2021

Changes to Referring Process for Advanced Diagnostic Imaging

Medicare regulations are changing – here’s what you need to know.

In response to the Protecting Access to Medicare Act (PAMA) of 2014, Section 218(b), the Centers for Medicare and Medicaid Services (CMS) requires providers to utilize approved clinical decision support (CDS) technology when ordering advanced diagnostic imaging services for Medicare fee-for-service patients with certain suspected conditions.

When the process is utilized, a HCPCS modifier and G-code is added to the order for submission to CMS along with the claim.

While 2021 is considered a preparatory and educational year, on January 1, 2022, CMS will begin withholding payment to radiologists and other furnishing providers who read these studies if proof of consultation is not provided.  

In order to comply with this mandate as well as ensure reimbursement for our Medicare patients, we have implemented a CDS tool provided by Stanson Health. As a provider in our community who refers patients to our facilities, it is imperative that each MRI, CT, PET, and Nuclear Medicine order is accompanied by the HCPCS modifier & G-code, which is unique to each imaging order. 

The eight priority clinical areas are:

  • Coronary artery disease (suspected or diagnosed)
  • Suspected pulmonary embolism
  • Headache (traumatic or 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

NHRMC is offering the Stanson Health Provider Portal for practices that do not have access to an approved CDSM or solution provided by their Electronic Health Record (EHR). After the consultation with the Provider Portal, you will have the option to print a consultation summary that contains the required information to submit with your order. 

New Hanover Regional Medical Center will be implementing this requirement in the fall for all providers. Note that this is a CMS requirement for all organizations across the U.S. who care for Medicare fee-for-service patients. If your order does not have the HCPCS modifier and G-code information, patient scheduling will be delayed.

Please register for the portal at your earliest convenience.

See below for some FAQs about PAMA and the Stanson CDSM.

For additional information about the Protecting Access to Medicare Act, email PAMA@nhrmc.org or call 910-667-8290.

What is changing?

What is changing?

CMS will soon require consultation of Appropriate Use Criteria (AUC) through a qualified Clinical Decision Support Mechanism (qCDSM) for all advanced diagnostic imaging referrals ordered for patients covered by Medicare.

New Hanover Regional Medical Center will begin offering a CDSM consultation tool in 2021, when providers may voluntarily begin using AUC for advanced diagnostic imaging referrals.

Beginning January 1, 2022, CMS will begin issuing penalties for those not using AUC for these referrals.

What the CDSM does

What will the Clinical Decision Support Mechanism tell me?

The CDSM will provide information regarding appropriate use for advanced diagnostic imaging studies for certain diagnoses as determined by CMS. The tool will provide an identification number with each consult as well as one of the following status statements:

  • Appropriate
  • Not appropriate
  • Not applicable

Providers will be required to include both the identification number and status for each referral.

Accessing the CDSM

How can I access a Clinical Decision Support Mechanism?

NHRMC Medical Staff and clinical staff members will have access to an approved CDSM tool through Epic. Providers and practices who are not connected to NHRMC’s Epic electronic medical record will need to gain access to a CDSM tool either through their own electronic medical record system (if that option is available) or through another qualified CDSM tool.

NHRMC will provide non-Epic users access to a CDSM portal to ensure compliance with CMS regulations.

What is Advanced Diagnostic Imaging

What tests are considered "advanced diagnostic imaging?"

Advanced diagnostic imaging tests that will require consultation with a CDSM include:

  • MRI
  • CT scans
  • PET scans
  • Nuclear medicine studies

Only those studies performed in an outpatient setting require consultation with a CDSM.

Which clinical areas require AUC

What are the clinical areas that will require consultation of Appropriate Use Criteria (AUC)?

CMS has identified eight priority clinical areas base don how common and widespread a condition, disease, or symptom complex is; the variation of image ordering; strength of evidence supporting imaging services, and relevance to the Medicare population. Those eight priority clinical areas are:

  • 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

Who can complete this process

Who can complete the consultation?

Consultation with a CDSM can be performed by most clinical staff under the direction of the ordering provider.