New Criteria For Advanced Diagnostic Imaging Services

Changes Results of PAMA; New Requirements Begin Jan. 2018

New reporting requirements for healthcare providers are scheduled to go into effect in January 2018 as a result of the mandate in Section 218(b) of the Protecting Access to Medicare Act of 2014 (PAMA). PAMA requires CMS to establish a program to promote ordering physicians to consult “appropriate use criteria” (AUC) prior to ordering advanced diagnostic imaging tests for Medicare beneficiaries.

What is AUC? AUC is defined as criteria developed or endorsed by national professional medical specialty societies, or other provider-led entities, to assist ordering professionals and furnishing professionals in making the most appropriate treatment decision for a specific clinical condition for an individual.  To the extent feasible, AUC must be evidence-based. It is anticipated that by the end of June 2017, CMS will announce qualified clinical decision support mechanisms (CDSMs) or software that provide AUC information to the provider and that will assist the provider in making the most appropriate treatment decision for a patient’s specific clinical condition.   

The PAMA legislation mandates that AUC be consulted for all advanced diagnostic imaging services. CMS has identified “priority clinical areas” such as CAD, suspected PE, headache, cancer of the lung, and various common areas of pain (hip, low back, and shoulder) but only for the purposes of identifying ordering professionals who are outliers and who may be failing to comply with AUC. The statute requires the identification of outlier ordering professionals, who will be subject to a prior authorization requirement beginning on January 1, 2020. 
If you have further questions about the new regulations and how to prepare for them, consult your healthcare attorney.

This news alert is created by the attorneys Healthcare Practice Group at FridayEldredge & ClarkLLP. The information provided is not a substitute for legal advice and should be considered for general guidance only. Please contact one of our attorneys for specific legal advice regarding this matter. 

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