As described by the Centers for Medicare and Medicaid Services (CMS), the Protecting Access to Medicare Act (PAMA) of 2014, Section 218(b), established a new program to increase the rate of appropriate advanced diagnostic imaging services provided to Medicare beneficiaries.

Examples of such advanced imaging services include:

  • computed tomography (CT)
  • positron emission tomography (PET)
  • nuclear medicine, and
  • magnetic resonance imaging (MRI)

Under this program, at the time a practitioner orders an advanced diagnostic imaging service for a Medicare beneficiary, he/she, or clinical staff acting under his/her direction, will be required to consult a qualified Clinical Decision Support Mechanism (CDSM).

CDSMs are electronic portals through which appropriate use criteria (AUC) are accessed. The CDSM provides a determination of whether the order adheres to AUC, or if the AUC consulted was not applicable (e.g., no AUC is available to address the patient’s clinical condition).

A consultation must take place at the time of the order for imaging services that will be furnished in one of the below settings and paid for under one of the below payment systems. Ultimately, practitioners whose ordering patterns are considered outliers will be subject to prior authorization. Information on outlier methodology and prior authorization is not yet available.

This program impacts all physicians and practitioners (as defined in 1861(r) or described in 1842(b)(18)(C)), who order advanced diagnostic imaging services and physicians, practitioners and facilities that furnish advanced diagnostic imaging services in a physician’s office, hospital outpatient department (including the emergency department), an ambulatory surgical center or an independent diagnostic testing facility (IDTF) and whose claims are paid under the physician fee schedule, hospital outpatient prospective payment system or ambulatory surgical center payment system.

The implementation for AUC has been delayed a number of times, most recently as a result of the COVID-19 Public Health Emergency (PHE). The full implementation of the program is currently set to take place the January following the end of the PHE.

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