The Protecting Access to Medicare Act (PAMA) of 2014 requires image providers to consult the Appropriate Use Criteria (AUC) before ordering imaging exams of Medicare patients. These consultations must be made through an electronic clinical decision support system (CDSS), which provides healthcare professionals with critical medical information. PAMA required imaging practices to incorporate AUC into their clinical workflows by January 1, 2018, including the submission of documentation of CDS use on Medicare claims.
This requirement will change workflows in the following areas:
- R-SCAN network
- Outlier providers
- Outpatient orders
- Vendor requirements
The American College of Radiology (ACR) maintains the Radiology Support, Communication and Alignment (R-SCAN) network, which is funded by a grant from the Centers for Medicare and Medicaid Services (CMS) Transforming Clinical Practice Initiative (TCPI). R-SCAN supports AUC for radiologists and aids healthcare providers in meeting PAMA requirements for imaging studies. It also provides practices with access to web-based tools and CDS systems for the purpose of optimizing those studies.
R-SCAN teams collect evidence-based data and generate reports that help to identify inappropriate exams. These reports provide the basis for educating clinicians and staff members on the appropriate use of imaging studies. R-SCAN’s CDS also facilitates communication between radiologists and healthcare providers, allowing radiologists to become more valuable resources for administrators. CMS promotes R-SCAN use by awarding participants with Improvement Activity credits, which count towards CMS’s Quality Payment Program. Over 130 practices in the United States currently use R-SCAN, which includes more than 4,000 radiologists.
The CMS will designate certain healthcare referrers as outliers according to their adherence to the following eight clinical areas, beginning in 2020:
- Coronary artery disease
- Pulmonary embolism
- Low back pain
- Shoulder pain
- Lung cancer
- Neck pain
- Hip pain
These diagnostic groups were selected because they have the highest use of advanced imaging studies and collectively account for about 40 percent of Medicare’s imaging studies. CMS will designate up to five percent of all imaging practices as outliers, which will be required to obtain pre-authorization for Medicare patients. Radiologists and other imaging providers should therefore ensure that their practices implement a CDS mechanism that includes all eight of these clinical areas. This mechanism should also include the analytics needed to identify the practices that will become outliers.
CMS’s Medicare Physician Fee Schedule final rule addresses the effect of PAMA’s mandate on outpatients. It requires healthcare providers to apply CDS practices for all imaging studies on Medicare fee-for-service patients. The ordering providers must use CDS before ordering the images, and the furnishing provider must report the consultation to CMS.
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CMS will use claims-based reporting requirements to track CDS compliance, which will be expanded in 2018. CMS has also suggested practices that will help furnishing providers obtain full reimbursement for Medicare claims in anticipation of these changes in reporting requirements. These suggestions include indicating the order’s AUC approval status. CMS also recommends that ordering providers indicate the national provider’s identification number on the order and the CDS mechanism that was consulted when ordering the image.
CMS released its first list of approved CDS vendors in June 2017 and will publish a new list annually. CMS invites new vendors to apply each year and also provides the current requirements for qualifying CDS mechanisms. The most important of these requirements includes documentation of the consultation with a unique identifier. The CDS mechanism must also incorporate AUC from more than one approved source and provide aggregate feedback to the provider each year.
M-Scribe Technologies, LLC can help your practice comply with current imaging reporting requirements and other practices in auditing, billing and coding. Contact us at 770-666-0470 or email us at firstname.lastname@example.org for a free analysis of your practice’s needs.