Protecting Access to Medicare Act (PAMA)

Starting January 1, 2018...

Medicare reimbursement for advanced outpatient imaging procedures (CT, MR, NM, PET)  will be at risk if providers do not meet the requirements of the Appropriate Use Criteria (AUC) Program initially set forth in the Protecting Access to Medicare Act (PAMA, 2014).  

Requirements of the AUC Program

  1. Ordering professionals must consult Appropriate Use Criteria (AUC) for advanced outpatient imaging (CT, MR, NM, PET) orders.
  2. Only AUCs from qualified Provider-Led Entities (qPLE) may be used under this program. 
  3. Ordering professionals must access AUCs through a qualified clinical decision support mechanism (qCDSM).
  4. Claims by furnishing professionals must specify CDS consultation (to be clarified in MPFS CY 2018 Rule).
  5. Ordering professionals identified as outliers must obtain preauthorization as soon as January 1, 2020. 

Appropriate Use Criteria

"AUC are a set of individual criteria that present information in a manner that links a specific clinical condition or presentation, one or more services, and an assessment of the appropriateness of the service(s). Evidence-based AUC for imaging can assist clinicians in selecting the imaging study that is most likely to improve health outcomes for patients based on their individual context." - Centers for Medicare and Medicaid Services, MPFS CY 2017

Eight Clinical Priority Areas

Although all ordering professionals must consult CDS for advanced outpatient imaging, CMS has identified eight priority clinical areas that must be reported starting January 1, 2018. The eight clinical areas are:

  • Coronary Artery Disease (suspected or diagnosed)
  • Suspected Pulmonary Embolism
  • Headache (traumatic or 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

Qualified Provider-Led Entities (qPLE)

Qualified provider-led entities (qPLE) are approved to "develop, modify or endorse" appropriate use criteria. To date, the following eleven qPLEs have been approved through an annual application process. The second round of qPLEs will be released in June 2017.

  • American College of Cardiology Foundation
  • American College of Radiology
  • Brigham and Women's Physicians Organization
  • Center for Diagnostic Imaging (CDI) Quality Institute
  • Intermountain Healthcare
  • Massachusetts General Hospital, Department of Radiology
  • National Comprehensive Cancer Network
  • Society for Nuclear Medicine and Molecular Imaging
  • University of California Medical Campuses
  • University of Washington Physicians
  • Weill Cornell Medicine Physicians Organizations

MedCurrent's Path to qPLE program

The deadline for the next round of qPLE applications is January 1, 2017 and yearly thereafter. Speak to MedCurrent to understand the value of being a qPLE and our simple approach to achieving qualified status.

Qualified Clinical Decision Support Mechanism

A clinical decision support mechanism (CDSM) is “an interactive, electronic tool for use by clinicians that communicate AUC information to the user and assists them in making the most appropriate treatment decision for a patient’s specific clinical condition." - Center for Medicare and Medicaid Services, MPFS CY 2017

CDSM Approval Process Timeline