All you need to know

We realize that the Appropriate Use Criteria (AUC) validation mandate of PAMA is not one of those areas that healthcare professionals are likely to be fully familiar with – especially those focused on assisting patients and without the time to research the subject. We’ve therefore provided this frequently asked questions (FAQ) page to help you understand the background and requirements of the AUC mandate. Please note that, while we have summarized some aspects in our own language, we are also providing specific instructions directly from the Centers for Medicare and Medicaid (CMS) web page to ensure complete consistency. If you have questions, we encourage you to reference the CMS AUC website for definitive answers.

Q. What is the PAMA AUC requirement?

PAMA is a broad set of legislation applying to the federally required activities of healthcare professionals and organizations delivering services on behalf of Medicare and Medicaid patients. The law was originally passed in 2014 and has been periodically updated since then. PAMA includes a section that mandates that “ordering professionals” (providers and practitioners) must perform a particular process of validating the use of advanced imaging procedures for Medicare/Medicaid patients against CMS-approved electronic “appropriate use criteria” (AUC) guidelines. If this process is not followed, CMS may potentially deny reimbursement for the procedures and may identify the ordering professional as an outlier subject to future consequences such as having to pre-authorize orders. Currently, all providers are expected to perform AUC validation in a test and educational mode with monitoring and enforcement activities to begin at a later date to be specified by CMS.

Per the CMS website, “The Protecting Access to Medicare Act (PAMA) of 2014, Section 218(b), established a new program to increase the rate of appropriate advanced diagnostic imaging services provided to Medicare beneficiaries…”

“…Under this program, at the time a practitioner orders an advanced diagnostic imaging service for a Medicare beneficiary, he/she, or clinical staff acting under his/her direction, will be required to consult a qualified Clinical Decision Support Mechanism (CDSM). [the LogicNets AUC Solution is a qualified CDSM.] The CDSM provides a determination based on approved guidelines from Provider Led Entities of whether the order adheres to the defined Appropriate Use Criteria (AUC), or if the AUC consulted was not applicable (e.g., no AUC is available to address the patient’s clinical condition). A consultation must take place at the time of the order for imaging services that will be furnished by an imaging center (or furnishing provider). Ultimately, practitioners whose ordering patterns are considered outliers will be subject to prior authorization. Information on outlier methodology and prior authorization is not yet available.”

Q. What is a qCDSM?

The CMS defines a CDSM as: “A Clinical Decision Support Mechanism (CDSM) is an interactive, electronic tool for use by clinicians that communicates appropriate use criteria (AUC) information to the user and assists them in making the most appropriate treatment decision for a patient’s specific clinical condition. They may be modules within or available through certified electronic health record (EHR) technology.”

CMS has required that technology vendors developing a CDSM for Medicare providers to use for AUC validation must apply for and be authorized by CMS. A “qCDSM” is a CDSM that has received such qualification from CMS. LogicNets is a qCDSM that is accessed as a cloud service by both interactive users and as an embedded service for EHR systems. CMS assigns a “G-code” for each qCDSM product that is submitted by furnishing providers in order to seek reimbursement. The LogicNets G-Code is G-1019.

Q. What is a PLE or qPLE?

CMS has sought to ensure that providers and practitioners ordering advanced imaging services validate appropriateness using Appropriate Use Criteria guidelines that are evidence-based, developed by qualified professionals, and are proven in the field. They have therefore required that the AUC guidelines used for validation under PAMA be developed by “qualified provider-led entities” (qPLEs). The CMS website defines a PLE as “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. Once a PLE is qualified, the appropriate use criteria (AUC) developed, modified or endorsed by the entity are considered specified applicable AUC.”

The LogicNets qCDSM processes its validations using AUC Guidelines developed and licensed to LogicNets by Intermountain Healhcare and the National Comprehensive Cancer Network (NCCN).

Q. Which imaging services are subject to the AUC validation mandate?

The AUC validation mandate applies to all “advanced imaging services”. Per the CMS website, these generally include:

  • Computed tomography (CT)
  • Positron emission tomography (PET)
  • Nuclear medicine
  • Magnetic resonance imaging (MRI)

CMS maintains educational materials on the AUC program that specify by CPT code all procedures that are considered subject to AUC validation.

Q. What are the clinical areas for which AUC guidelines must be checked?

While all advanced imaging procedures must be processed by a CDSM, the only guidelines that must be made available in the CDSM and which must be used for validation are in the “8 priority clinical areas” specified by CMS.

Advanced imaging orders in the following priority clinical areas must be validated against an AUC guideline provided by a qPLE:

  • Coronary artery disease (suspected or diagnosed)
  • Suspected pulmonary embolism
  • Headache (traumatic and nontraumatic)
  • Hip pain
  • Low back pain
  • Shoulder pain (to include suspected rotator cuff injury)
  • Cancer of the lung (primary or metastatic, suspected or diagnosed)
  • Cervical or neck pain

Advanced imaging orders outside of these priority clinical areas must still be processed by the CDSM in order to generate reimbursement codes, but they may be processed without having been checked against a clinical guideline.

Q. Which patient scenarios require AUC validation and which are exempted?

AUC validation is only required for patient cases where patient care and reimbursement is being handled under Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP). The process is not relevant or required for imaging services reimbursed under private insurance plans.

Furthermore, emergency patient cases are exempt from the AUC validation requirement. When submitting for reimbursement of emergency Medicare cases, a special HCSPCS modifier is used. Note that, while the CDSM does not need to be referenced to use this code, the LogicNets AUC Solution allows the user to indicate an Emergency patient scenario and it bypasses the processing of the AUC guidelines and generates this code.

Q.What reimbursement information is generated from a CDSM consultation

The CDSM should provide the following information to document a completed consultation:

  • The service being validated (CPT Code)
  • Patient identifier and basic demographics – name, gender, age
  • The AUC Guideline(s) that were used matching the patient scenario
  • The qPLE responsible for the guideline(s) used
  • The consultation outcome: “Appropriate”, “Not-Appropriate”, “Insufficient Patient Data”, and “No Criteria Apply”
  • The HCPCS modifier code – a two-character string indicating how the consultation was performed
  • The G-Code – which CDSM was used
  • The Unique Consultation ID (UCI) – a unique alphanumeric code that can be used to identify the specific consultation completed with the CDSM. With LogicNets this is a 45-digit code.

The LogicNets AUC Solution provides access to this result information during the consultation process and subsequently in history views and through the AUC Reporting Module.

Q.What is the required AUC deployment timeline?

CMS will soon require all provider organizations processing Medicare and Medicare patient services have been expected to begin the process of educating themselves on their requirements and deployment needs and beginning operational testing. The current phase of adoption has been designated by CMS as “The EDUCATIONAL AND OPERATIONS TESTING PERIOD.”

According to the CMS AUC web pages, CMS “encourage[s] stakeholders to use this period to learn, test and prepare for the AUC program.”

When CMS indicates the end of this period, the AUC validation mandate becomes mandatory for all providers and practitioners performing advanced imaging services on behalf of Medicare and Medicare patient cases. Already, in anticipationof enforcement, many furnishing providers will likely not accept advanced imaging orders without CDSM consultation for AUC outcomes. When enforced, furnishing providers will not be reimbursed by CMS without the AUC outcome codes. Further, CMS will monitor advanced imaging orders by ordering physicians and potentially will identify them as outliers if they fail to comply with the mandate. Outliers may face “consequences” as yet unspecified by CMS for their lapses in performing AUC validation, but which have been suggested to include a requirement for outlier physicians to gain CMS pre-authorization prior to issuing advanced imaging orders.