Appropriate Use Criteria
Protecting Access to Medicare
Heard of the acronyms PAMA or CDSM? If not, listen closely over the next few months. On March 31, 2014, Protecting Access to Medical Act (PAMA) passed – and CMS was mandated by Congress to implement an Appropriateness Use Criteria (AUC) testing period using Clinical Decision Support Mechanisms (CDSM) beginning Jan 2020. In January 2020 practices will need to include the HCPCS G-code (shows that AUC was consulted) on their claims for advanced diagnostic imaging services (CT, MR, Pet, Nuclear Med) for Medicare Part B patients ONLY (excluding Advantage plans). The HCPCS QQ Modifier will demonstrate adherence to the qualified CDSM, an interactive and electronic tool for use by clinicians that assists in making the most appropriate treatment decision for a patient specific to the clinical condition.
If an exam is ordered during the testing period between Jan 1, 2020 and Dec 31, 2020 and it is determined that the exam selected is not the appropriate imaging exam, the patient can still be scanned and the rendering provider can be paid. Beginning January 1, 2021 providers will want to avert penalties should they not adhere to the recommended exam. EMR and Billing software vendors should be communicating their preparedness by Fall 2019. Windsong’s team is also preparing for the testing period and we intend to work closely with our referring providers to meet their needs.
Frequently Asked Questions
Who Can Access the CDSM?
Only licensed clinical staff, LPNs, or RNs, (operating under the supervision of the ordering provider who should be informed) will have access to the Clinical Decision Support Mechanism.
Can a code be added on a later claim to get favorable payment?
No, the AUC consultation information must be submitted with the imaging exam claim.
When will the free National Clinical Decision Support Care Select be available?
The free Care Select tool will be made available in November of 2019 for providers without an integrated EMR solution.
Will all advanced imaging exams require the CDS code or is it just the priority areas?
AUC consultations will be required for all advanced diagnostic imaging services (CT, MR, PET, Nuclear medicine). In the event no AUC exists for the services, a “not applicable” modifier may be used.
How will this impact the current workflow?
The CDSM will ask for age, gender, signs and symptoms and the test being ordered. AUC are triggered off the Clinical Indication or “Reason for exam”. Based on indication, an appropriateness rating will then be generated. The referring physician will need to provide the rendering physician with the codes showing that AUC has been consulted and level of adherence.
Which exams need an Appropriate Use Code?
CT, MRI, PET and NUCLEAR MED orders for Medicare patients are the only exams that will require the AUC code.
How and where do I access the Appropriateness Use Criteria tool?
Tools may be modules within or available through certified electronic health record technology (as defined in Section 1848(o)(4) of the Act, private sector mechanisms independent from certified HER technology or those established by CMS. Certified and Preliminary qualified tools can be found at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/CDSM.html.
For more information contact Gina at firstname.lastname@example.org or call 716.631.2500, ext. 2240. Additional information can be found at: