UPDATE – Protecting Access to Medicare Act (PAMA): Appropriate Use Criteria (AUC) for Advanced Imaging Services

The proposed rule for the Physician Fee Schedule (PFS) for calendar year 2018 is scheduled to be published on July 21, 2017. Within this proposal is additional information regarding the Appropriate Use Criteria (AUC) for advanced Imaging services.

Evidence-based AUC for advanced imaging will assist clinicians in selecting the imaging study that is most likely to improve health outcomes for patients based on their individual clinical presentation. CMS defined qualified Clinical Decision Support Mechanisms (CDSM) as an interactive, electronic tool for use by clinicians that communicates AUC information and assists them in making the most appropriate treatment decision for a patient’s specific clinical condition.

The proposed rule is recommending a start date of January 1, 2019. On or after January 1, 2019, ordering professionals must consult an applicable AUC using a qualified (CDSM) when ordering advanced imaging services. These services are defined by CMS as MRI, CT and nuclear medicine imaging such as PET scan. The professional providing the service must report the ordering professional’s consultation information on the Medicare claim to be compensated for the service provided.

In the CY 2017 PFS final rule, CMS identified circumstances where the ordering professional would not be required to consult an AUC, these include:

  • Emergency services provided to individuals with emergency medical conditions
  • For inpatients and for which payment is made under Medicare Part A
  • By ordering professionals who are granted a significant hardship exception to the Medicare EHR Incentive Program

 

CMS defined the applicable payment system for AUC consultation and reporting requirements to include:

  • The physician fee schedule
  • The prospective payment system for hospital outpatient department services
  • The ambulatory surgical center payment system

 

CMS has identified the first list of priority clinical areas to be:

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

 

The following are proposed claim reporting information for the furnishing professional:

  • Identify which qualified CDSM was consulted by the ordering professional
    • CMS is proposing to develop a list of G Codes to identify the CDSM consulted as well as when an AUC was not consulted through a qualified CDSM
  • Identify if the service ordered would adhere or would not adhere to specific AUC, or specified AUC was not applicable to the imaging service ordered
    • CMS is proposing to develop a series of modifiers to identify adherence as well as modifiers identifying exceptions such as patients with emergency medical conditions or an ordering professional with a significant hardship exception
  • The claim must also include the NPI of the ordering professional

 

The proposed G codes will be a line item for both professional and facility claims. One G code is expected to be reported for every advanced diagnostic imaging service provided and each G code will be accompanied by a modifier.

 

CMS is proposing a voluntary reporting period to begin July 2018. During this voluntary reporting period, CMS would continue to pay claims whether or not AUC is correctly reported. This will avoid unnecessary claim denials during the learning period as well as provide CMS an opportunity to make any needed claims processing adjustments.

 

We are expecting additional information to be published by CMS this fall in the CY 2017 PFS final rule. Meridian Medical Management will continue to monitor changes and updates to this program as they become available and will keep our clients informed of any changes.

For a list of Qualified Provider Led Entities (PLEs) and Qualified Clinical Decision Support Mechanisms or to access more information regarding Appropriate Use Criteria please go to:

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/index.html