PAMA Mandate Delayed

Year-long testing period requested for the use of clinical decision support for Medicare imaging

The Centers for Medicare and Medicaid Services (CMS) has requested that outpatient radiological procedure claims will not be denied in 2020 for failing to include codes that indicate the  prescribing physicians sought guidance from formal clinical decision support mechanisms. Instead, the Protecting Access to Medicare Act (PAMA) will go through a year-long testing period.

PAMA was scheduled go into effect on January 1, 2020. It would have required that physicians ordering advanced imaging exams for Medicare patients consult appropriate use criteria (AUC) through electronic clinical decision support (CDS) tools.

The pronouncement by CMS to delay PAMA was issued as a Change Request to inform Medicare Administrative Contractors that payments for eight priority clinical areas  –  coronary artery disease, suspected pulmonary embolism, headache, hip pain, low back pain, shoulder pain, cancer of the lung and cervical or neck pain – won’t be negatively impacted during 2020. However, the order notes that CMS is expecting to expand the program to include consultation of guidelines for all advanced diagnostic imaging services, not just those deemed priority clinical areas.

After Jan. 1, 2021, information on the ordering professional’s interaction with the clinical decision support tool, or an exception to the consultation, must be included with the claim submitted by the radiologic institution in order for the institution to be paid for providing imaging services.

While AUC-related information may not be consistently attached to imaging claims in 2020, CMS expects ordering professionals to begin consulting qualified CDS mechanisms regularly.

RSNA News will continue to monitor this story.

For More Information

Read the RSNA News article, “Radiology: Are You Ready for Clinical Decision Support Law in 2020?”

To read more about the impact of PAMA on diagnostic imaging in emergency departments, access the Radiology study, “Access to Medicare Act on Use of Advanced Diagnostic Imaging in the Emergency Department: An Analysis of the National Hospital Ambulatory Care Survey.”

For more history about PAMA, access the Radiology study, “New CMS Clinical Decision Support Regulations: A Potential Opportunity with Major Challenges.”