PAMA Resource Center

On January 1, 2020, CMS implemented a new mandate – section 218 of Protecting Access to Medicare Act (PAMA) – that changes the current prior authorization process for ordering certain advanced diagnostic imaging studies.

When ordering an advanced diagnostic imaging service for a Medicare beneficiary, a provider is required to consult a qualified Clinical Decision Support Mechanism (CDSM). CDSMs are electronic portals through which appropriate use criteria (AUC) is accessed. The CDSM provides a clinical Decision Support Number (DSN) denoting if the order adheres to the AUC. The CDSM replaces the previous prior authorization process for Medicare patients, is faster, and provides a more specific diagnosis as well as more information on the order.

The PAMA program started with a voluntary reporting period July 2018 to December 2019. CMS began auditing January 1, 2020. This will be an educational year with no penalty until January 1, 2021.

EMRs should be preparing to meet this mandate by embedding a qualified decision support mechanism within their software. Please check with your EMR to see how they will be supporting your office to meet this mandate. If your practice’s EMR will not be implementing a CDSM or if you don’t have an EMR, there are several free web portals that will provide a DSN.

As of Jan. 1, 2020, Munson Healthcare is asking that any order for radiology testing (CT, MRI, PET, nuclear medicine) for a Medicare patient include a decision support number. However, in order to give EMRs and practices time to implement this in your office, MHC will not require the DSN until a designated time determined by leadership. This will be communicated shall it occur prior to 2021.

For more, read the PAMA FAQ.

Helpful Websites

CMS-PAMA Regulations