The Protecting Access to Medicare Act (PAMA) of 2014 established the Appropriate Use Criteria (AUC) Program to increase the rate of appropriate advanced diagnostic imaging services provided to Medicare beneficiaries. Examples of such advanced imaging services include:

  • Computed tomography (CT)

  • Positron emission tomography (PET)

  • Nuclear medicine

  • Magnetic resonance imaging (MRI)

At the time a provider orders an advanced diagnostic imaging service for a Medicare Part B beneficiary, the ordering provider or their clinical staff proxy will be required to consult a qualified Clinical Decision Support Mechanism (CDSM). CDSMs are electronic portals through which AUC is accessed. The CDSM provides a determination of whether the order adheres to AUC, or if the AUC consulted was not applicable (e.g., no AUC is available to address the patient’s clinical condition). (Source: CMS)

For complete information, refer to CMS's Appropriate Use Criteria Program webpage.

When does the AUC program start?

January 1, 2021 (CY 2021)

CY 2020 (period starting January 1, 2020) is an educational and operations testing period. Claims will NOT be denied for failing to include AUC consultation information during 2020.

Does NextGen Office have a CDSM integration?

NextGen Office EHR/PM is working with National Decision Support Company (NDSC) to develop their integrated solution for this requirement. They hope to have this solution ready for our clients later in 2020. We will share more information as we get closer to going live with our solution.

Can I start using a CDSM now?

Yes. While not required for CY 2020, if you want to begin manually submitting codes to your radiology partners, NDSC has a free option that is available online.

CareSelect Imaging - Open Access enables ordering providers and their proxies to consult clinical decision support and generate the required data for a payable claim for all advanced imaging exams as required by PAMA.

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AVS Medical

Written by AVS Medical