What You Need to Know About the Physician/Radiologist Partnership Under PAMA

By Infinx
August 9, 2017

As of January 1, 2018, physicians are going to have to abide by new, stricter standards when ordering imaging for patients. The Protecting Access to Medicare Act (PAMA) will require physicians to consult appropriate use criteria (AUC) before ordering diagnostic imaging like CT, MRI, PET and nuclear medicine tests. It’s designed to curb overutilization and is a requirement that comes with teeth;

  • AUC consultation must be documented on each order to gain approval from the radiologist or other provider.
  • If the radiologist approves an imaging order without AUC documentation, they will not receive Medicare reimbursement.

The new rule has made sure that radiologists have no incentive to conduct tests that do not have AUC documentation. The ACR says “…no rendering provider – radiologist or otherwise – may receive Medicare payment for an advanced imaging exam if the referring provider does not verify that imaging AUC were consulted.”

The only exceptions to this rule are emergency room tests ordered under EMTALA and inpatient exams. The ACR says that limited exceptions may also be granted for rural providers with limited internet access.

Documenting AUC access

The American College of Radiology (ACR) anticipates that providers will be issued a decision support number that will become their identifier. They will enter this number into the document when consulting AUC. The AUC will be integrated into stand alone electronic decision support systems or CDS software that is embedded into the physician’s EHR.

Responsibility lies with the referring physician

The responsibility of checking AUC and documenting that it was checked rests entirely with the referring provider. The ACR says that:

  • Ordering physicians cannot shift the requirement to consult the guidelines to radiologists.
  • Imaging providers cannot perform AUC administrative duties for referring providers.
  • All imaging providers may refuse Medicare referrals lacking the DSN and not be competitively disadvantaged.

The intent of the rule is to move physicians away from ordering imaging tests as a strategy to reduce risk and exposure and reduce overutilization. However, if the rule walks out as intended, it may increase coordination between physicians and radiologists, reducing risk as they work together to identify tests that are appropriate. Radiologists can serve as an expert resource to hospitals and referring providers, helping to transition health care from a volume based practice to value-based care.

We’ve got your back on strict AUC requirements

Advanced clinical decision support (CDS) systems that provide immediate preauthorization for imaging will help physicians to navigate the appropriate-use gauntlet. Our preauthorization solution will help facilitate selecting the right exams, through preauthorization standards, in concert with radiologists and quality/safety/appropriateness standards. The rules may be tightening but we’ve got your back. Insurance verification and preauthorization best practices will put you in good shape for smooth sailing through the AUC process.

About the Author



Infinx provides innovative and scalable payment lifecycle solutions for healthcare practices. Combining an intelligent, cloud-based platform driven by AI with our trained and certified coding and billing specialists, we help clients realize revenue, enabling them to shift focus from administrative details to billable patient care.

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