Information on outlier methodology and prior authorization is not yet available. Ultimately, practitioners whose ordering patterns are considered outliers will be subject to prior authorization. A consultation must take place at the time of the order for imaging services that will be furnished in one of the below settings and paid for under one of the below payment systems. The CDSM provides a determination of whether the order adheres to AUC, or if the AUC consulted was not applicable (e.g., no AUC is available to address the patient’s clinical condition). CDSMs are electronic portals through which appropriate use criteria (AUC) is accessed. 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). Examples of such advanced imaging services include: 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.
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