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The Road to Payment Reform: A Guide to PAMA Compliance for Advanced Imaging

10/21/19

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By:

Adam Fairbourn, Portfolio Executive, Capital and Imaging

Overuse of advanced imaging modalities has been scrutinized by policymakers as a factor contributing to unsustainable levels of health care spending in our nation. That scrutiny was the driving force behind the passage of the Protecting Access to Medicare Act of 2014 (PAMA). This federal law includes a CMS mandate that ordering physicians consult Appropriate Use Criteria (AUC) using a qualified Clinical Decision Support Mechanism (CDSM) when ordering advanced imaging procedures such as CT, MRI, nuclear medicine and PET/CT. Following a one-year education and testing period in 2020, the punitive measures of PAMA are expected to take full effect on Jan. 1, 2021.

For providers, the road to organizational compliance with this mandate, and the effect it will have on their reimbursement, is still unknown for most health systems. In fact, one radiologist I recently spoke with said it felt like Dorothy from The Wizard of Oz, wandering down the Yellow Brick Road looking for the Emerald City. I chuckled at the analogy and then noted that what helped Dorothy was having the right friends on her journey. I explained that in order to meet the compliance deadline and avoid reimbursement penalties, diagnostic imaging administrators will need to lock arms with others to gather support (the Tin Man’s heart), build a system (the Scarecrow’s brain) and maintain compliance (the Lion’s courage).

Gathering support for the change

Gathering support begins with engaging physicians. Since they will be interacting with the CDSM, ordering physicians and their staff will need support for using CDSM tools, along with a reliable point of contact for questions when ordering advanced imaging procedures for Medicare beneficiaries. Current CDSM platforms do not provide a hard stop to providers who order an inappropriate exam, but only tracks the NPI of physicians who consistently force orders that are contrary to AUC. If you’re wondering which referring physicians to focus your outreach on, CMS has provided a list of priority clinical areas where CDSM mechanisms will focus the most.

Many times, exams that are forced through the mechanism can reveal opportunities for ordering physicians to be consulted, preferably by a radiologist peer, toward a more appropriate exam for their clinical question. With radiologist oversight, exam protocols can be standardized across modalities and matched up with AUC to streamline CDSM usage and guide enforcement later. It also helps to have a radiologist leader who will champion the initiative from its inception, ensure practices match up with policy, and serve as a point of contact for referring physicians. 

Collaborative relationships between ordering and service providers can enhance usage of the CDSM, increase the number of appropriate exams and mitigate future conflicts. Now that the physicians have joined us on the road to the Emerald City, we are ready to build the system!

Build a CDSM System

If you’re wondering what was going on between the passage of PAMA in 2014 and the roll-out date of 2021, the gap in time was to allow for provider-led entities (PLEs) to approve AUCs and provide them to CDSM platforms for use. Once the AUCs were in place, CMS began qualifying CDSM platforms that could be used alone or integrated into electronic medical records (EMR). There are currently a variety of platforms to choose from, but leveraging your current EMR would likely be the best bet.

Start by contacting your current EMR provider to investigate CDSM options before divisional budgets are due. The cost of adding a CDSM platform is certainly justified considering the financial penalties of not using one. Be sure to keep physician leaders engaged during this phase as well. Aim for intuitive workflows that increase communication between ordering and provider physicians during order placement in the EMR.

Also, don’t neglect to consider those physicians who are still adamant about faxing handwritten orders — the rules and penalties still apply. Non-emergent orders from the emergency department will also require a proactive approach to avoid conflict. Providing ordering physicians with access to approved protocols and published PLE AUCs can reduce the tendency to force exams through the CDSM mechanism.

Establish a process to ensure compliance

Enforcing an effective CDSM should not be a reactionary process. Imaging orders should also be reviewed well in advance of the patient arriving at the clinic and staff should be trained to proactively identify and manage inappropriate orders.

Designate a CDSM team that consists of an imaging staff member or manager, a radiologist, a scheduler and a billing and coding representative. This team should be responsible for receiving, reviewing and managing imaging referrals to completion.

Also, don’t forget about the patient! The last thing you want is a patient finding out their exam has not been approved after they arrive for their appointment. Being proactive and contacting patients ahead of time is crucial.

Once the process is in place, track the effectiveness of the CDSM team to identify and engage physicians who are outliers and are risks for creating reimbursement penalties and denials.

The point here is don’t wait for the cyclone to sweep the house from Kansas, and don’t get caught sleeping in the poppy fields. While it’s possible that the CDSM deadline gets extended after the trial period, payment reform will remain the destination. The time is now to get started on CDSM implementation. Maybe the road isn’t yellow, and maybe we’re not headed to the Emerald City, but the journey is real and we’ll need the help of others to be successful. Payment reform in Washington will continue to change the health care landscape before our very eyes, but as Dorothy so eloquently stated, “There’s no place like home.”

To get started on CDSM implementation, following are links to guidelines and PLE information:

AUC Fact Sheet

Appropriate Use Criteria and Timelines

PLE information

CDSM information

Outreach and Education

ACR CDSM support

SNMMI AUC and MIPS update (2018)

SNMMI AUC Listings

ACR AUC Listings

McGinty, Geraldine B. Clinical Decision Support: Moving Forward Together. Journal of the American College of Radiology, Volume 16, Issue 5, 661-662.

About the author. Adam Fairbourn is a portfolio executive on the diagnostic imaging team at Vizient. As a certified nuclear medicine technologist, he has 10 years of experience in clinical operations and currently serves as a state of Texas representative to the Society of Nuclear Medicine and Molecular Imaging Technologist Advocacy Group. Specializing in advanced imaging solutions, Fairbourn is passionate about helping health care organizations pursue cost, quality, access and sustainable market performance via operational effectiveness and strategic sourcing. 

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