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On January 1, 2018, radiologist across the nation will have to follow Medicare’s policy change regarding Clinical Decision Support (CDS) and Appropriateness Use Criteria (AUC). The Protecting Access to Medicare Act (PAMA) requires that referring health professionals consider the appropriateness use criteria of all advanced diagnostic imaging services before they are ordered for Medicare patients. These new Centers for Medicare and Medicaid Services (CMS) regulations include CT, MR, PET scans as well as nuclear medicine. CMS has suggested that healthcare providers closely monitor how many, as well as the type of, imaging services reported on each claim. Otherwise, health providers will not receive full reimbursement on claims submitted to Medicare.

Medicare’s issuing of PAMA requires the use of appropriate use criteria (AUC) before a healthcare professional orders advanced diagnostic imaging services. Furthermore, imaging providers need to select and implement a qualified Clinical Support Mechanism system before PAMA’s January 1st start date. If this system is not in place by the start of 2018, Medicare is expected to deny payments on some diagnostic imaging services. This means that health providers who submit advanced imaging exam insurance claims to Medicare, will not receive full payment for their services; unless these imaging services were verified through the AUC criteria. Additional collaboration is required between physicians and radiologists, due to the fact that imaging providers are not allowed to perform AUC administrative duties for referring physicians.

Naturally, radiology professionals are concerned with Medicare’s PAMA. Especially as the January 1st start date approaches. Interestingly, imaging exams performed in the emergency department are included in this rule – except for the most emergent of cases (as defined under EMTALA). Inpatient exams are also exempted from the PAMA rule. The U.S. Department of Health and Human Services has suggested that limited exceptions will be made for rural healthcare providers with limited internet connectivity. The staff and Advanced Billing Consulting Services (ABCS RCM) is closely watching these changes and will continue to report on any updates. For additional questions on this topic or other medical billing questionsCONTACT US!

For additional information on PAMA and AUC/CDS:

“How Did We Get Here?” Brief on CDS

Appropriate Use Criteria Program

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Radiology, PAMA, CDS, AUC,