PAMA implementation: The road ahead

As of January 1, 2020, the Centers for Medicare and Medicaid Services (CMS) has implemented §218(b) of the Protecting Access to Medicare Act (PAMA) of 2014. The law was enacted by Congress to minimize the use of rarely appropriate advanced diagnostic imaging studies (radionuclide imaging, magnetic resonance imaging, and computed tomography) provided to Medicare beneficiaries.1 Under this program, at the time a practitioner orders an advanced diagnostic imaging study for a Medicare beneficiary, he/she will be required to consult a qualified Clinical Decision Support Mechanism (CDSM). CDSMs are electronic portals through which appropriate use criteria (AUC) are accessed. The CDSM provides a determination of whether the order adheres to AUC, or if the clinical scenario was not addressed by AUC. A consultation must take place at the time of the order for imaging services to be paid by Medicare. Ultimately, practitioners whose ordering patterns are considered “outliers” will be subject to prior authorization. Definition of “outliers” and methodology of prior authorization have not yet been established. This program impacts all practitioners who order advanced diagnostic imaging studies, regardless of specialty, as well as physicians and facilities that furnish advanced diagnostic imaging services in any setting, whether their claims are paid under the physician fee schedule or Hospital Outpatient Prospective Payment System (HOPPS).1 Since July 1, 2018, this program has been operating under a voluntary participation period. As of January 1, 2020, the program has entered an “Education and Operations Testing Period,” during which claims will not be denied for failing to include proper AUC consultation information. The program is set to be fully implemented on January 1, 2021, which means AUC consultations using qualified CDSMs are required, along with reporting of this information on the professional and technical claims for the advanced diagnostic imaging service. Claims that fail to comply will not be paid. CMS finalized 8 “Priority Clinical Areas” which will be used to benchmark providers according to their utilization of rarely appropriate imaging studies.1 Since known or suspected coronary artery disease evaluation is a priority clinical area, the vast majority of cardiac imaging studies will be subject to the initial roll-out of the AUC mandate. Furthermore, CMS has identified qualified “Provider Led Entities” (professional organizations) which have developed or endorsed applicable AUC.1 The AUC developed by the American College of Cardiology (ACC), the American Society of Nuclear Cardiology (ASNC), and many other professional societies are among those approved by CMS.2 As a result of PAMA implementation, there will be a massive shift wherein the burden of reducing inappropriate use will move largely from payers to providers. Most physicians are unprepared for this paradigm shift. …