Protecting Access to Medicare Act (PAMA)

Appropriate Use Fact Sheet

CMS explains more about appropriate use criteria for advanced diagnostic imaging. Learn More

Changes to Referring Process for Advanced Diagnostic Imaging

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

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 2020, when providers may voluntarily begin using AUC for advanced diagnostic imaging referrals.

Beginning January 1, 2021, CMS will begin issuing penalties for those not using AUC for these referrals.

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.

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 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.

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 the consultation?

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

Questions?

For additional information about the Protecting Access to Medicare Act, email PAMA@nhrmc.org, call 910-667-8290 or fill out the form below to contact a member of our team.

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