8-Part Series for Radiologists:
Protecting your Medicare Revenue Stream in 2017-2018
Part 4: Overview of PAMA and the Appropriate Use Criteria (AUC) for Imaging
In Part 4 we will take a break from MACRA and the Medicare Quality Payment Program and discuss PAMA, a law that specifically targets radiologists and imaging centers. PAMA stands for the Protecting Access to Medicare Act of 2014. Congress passed PAMA to address cost increases in three fields: advanced diagnostic imaging, specialized laboratory testing, and cardiology procedures. The law is very logical in its intent, though somewhat misguided in its original implementation path. The foundation of the act is to define Appropriate Use Criteria (AUC) in each of the three fields. The law currently has a direct impact on radiology fees as we will discuss below. First let's discuss the mechanics of PAMA and the AUC.
Why Create Appropriate Use Criteria (AUC)?
Appropriate Use Criteria (AUC) come from the application of evidence-based medicine in the ordering of high cost interventions. For advanced diagnostic imaging, it means that we order the best test at the right time for the clinical question we wish to answer. For example, for the patient with chronic headache, should we get a CT head with and without contrast or an MRI? For the patient with a mass, should we do an abdominal ultrasound or a CT with oral contrast? The conundrum is we want our first test to be the "best" test, and not the one that requires us to do a second study. So the law is directed toward the elimination of unnecessary/redundant tests based on the clinical presentation of the patient and the differential diagnosis. For advanced imaging, such as CT, MRI, PET and combination studies, the ordering physician should be selecting the best modality (i.e. the evidence-based, superior test) for his/her patient. As in imaging, the law prescribes a similar process for expensive laboratory testing and cardiology procedures. However, the radiology AUC are set for implementation first, followed by lab and cardiology in later years.
Who determines the AUC?
PAMA allowed organizations to submit applications to become the "experts" for the AUC. These experts are known as "provider-led entities" (PLE). A PLE means "a national professional medical specialty society or other organization that is comprised primarily of providers or practitioners who, either within the organization or outside of the organization, predominantly provide direct patient care." (CMS.gov). The American College of Radiology (ACR) was an early author of AUC. However, as of June 2017, 17 PLEs are now approved (See LIST of PLEs). The bottom line is there is a path to be an author of the AUC and you must be approved as a PLE by CMS. You cannot self-proclaim yourself as a PLE or purveyor of AUC.
Since Medicare impacts adults over 65 and persons with disabilities, it is important to note that we are referring to AUC for adult imaging studies. However, there are organizations developing pediatric standards for AUC, but those would have little immediate impact under the new law. It is critical in children as well to avoid unnecessary ionizing radiation and costs from inappropriate imaging studies.
How are the AUC applied?
The law indicates that a clinical decision support system (CDSS) containing the AUC should be applied to all advanced diagnostic imaging studies performed on non-emergent, ambulatory patients. This has several implications, therefore, for the impact of PAMA:
- PAMA does not apply to inpatient imaging studies or those done emergently.
- PAMA does apply to outpatient advanced diagnostic imaging studies.
- PAMA does apply to studies done in the Emergency Department if they can be determined to be "non-emergent".
- The CDSS applying the AUC needs the clinical data in order to function.
- AUC need to be applied at the time of ordering the study.
- Since radiologists are not the ones ordering the test, the CDSS should reside with the "ordering physician."
- Since the CDSS requires clinical data to drive its logic, the ideal location for this to occur is within the electronic medical record (EMR) and leverage the electronic health record (EHR) of the patient.
- The documentation that AUC has been applied upon ordering should accompany the order.
So the impetus of applying CDSS with AUC should occur upon assessing the patient and in the process of ordering, not at the imaging center at the time of the study. Unfortunately, the law currently penalizes the radiologist if the CDSS is not documented. CMS has proposed two changes to the rule as of July 2017 and they are now under consideration:
- Move the implementation date to January 1, 2019 rather than 2018.
- Eliminate the penalties to the radiologist and instead create incentives for the ordering physicians to adopt the AUC CDSS as an opportunity for the ordering physicians under the QPP MIPS.
We will discuss this further in Part 5.
If you missed:
Part 1: Introduction, CLICK HERE.
Part 2: Details of MACRA and the Quality Payment Program (QPP), CLICK HERE.
Part 3: How to Participate with QPP if you are a Radiologist who Qualifies, CLICK HERE.