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Protecting Access to Medicare Act

WakeRad UNC REX is an early adopter PAMA. This act requires referring providers to consult appropriate use criteria prior to ordering advanced diagnostic imaging services – CT, MRI, Nuclear Medicine and PET – for Medicare patients.

The Protecting Access to Medicare Act (PAMA) of 2014, Section 218(b), established a program to increase the rate of appropriate advanced diagnostic imaging services provided to Medicare patients. Examples of advanced imaging includes CT, PET, nuclear medicine and MRI.

Under PAMA, a referring provider must consult a qualified Clinical Decision Support Mechanism (CDSM) when ordering an advanced diagnostic imaging service for a Medicare patient. CDSMs are electronic portals through which appropriate use criteria (AUC) is accessed.

The CDSM determines if the order meets 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 when an order is placed in order to be paid by one of the systems below.

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.

This program impacts all physicians and practitioners (as defined in 1861(r) or described in 1842(b)(18)(C)) who order advanced diagnostic imaging services and physicians, practitioners and facilities that furnish advanced diagnostic imaging services in a physician’s office, hospital outpatient department (including the emergency department), an ambulatory surgical center or an independent diagnostic testing facility (IDTF) and whose claims are paid under the physician fee schedule, hospital outpatient prospective payment system or ambulatory surgical center payment system.

We offer free access to ACR Appropriate Criteria information similar to tools that integrate with EHR systems. The WakeRad UNC REX scheduling and billing team, in addition to our radiologists and physician liaisons, are also resources to ensure you have easy, actionable access to clinical decision support.


Does your EHR comply with PAMA?

Your EHR or other ACR tools can help your organization comply with PAMA. If it does NOT and you need assistance with a solution, please complete the below form or contact our physician liaison team at 919-788-7908.

Learn more: Advanced Practice Providers AUC Resources or How PAMA Affects Orders for Imaging 

  • Referring Provider

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