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2. Priority Clinical Areas

AUC validation is required for all advanced imaging services (see this CMS document for the full list of CPT codes: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11268.pdf ), and the CDSM uses specific guidelines for each distinct clinical area. Currently, however, PAMA only requires that guidelines be used under the AUC validation process for 8 specific priority clinical areas. Outside of these priority areas, clinicians must use the AUC process to generate reimbursement codes, but the process does not need to follow a guideline. The LogicNets CDSM is therefore capable of completing a consultation for non-priority clinical areas without referencing a guideline.

Priority clinical areas are defined in section 42 CFR 414.94(b) of the PAMA legislation as clinical conditions, diseases, or symptom complexes and associated advanced diagnostic imaging services identified by CMS through annual rulemaking and in consultation with stakeholders.

CMS finalized an initial list of priority clinical areas in the CY 2017 Physician Fee Schedule Final Rule and established the list in 42 CFR 414.94(e)(5). Data used to inform this rule is available at Proposed_Priority_Clinical_Area_Appendix2.

Mandatory Priority Clinical Areas

  • 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

If an advanced imaging order is requested for other clinical areas you still need to validate the order with our CDSM. In this situation the CDSM generates a result indicating that no criteria apply. The corresponding result codes will need to be included in the reimbursement details.

 

LogicNets' CDSM uses the guidelines from Intermountain Healthcare. More information on these guidelines can be found here: https://intermountainhealthcare.org/services/imaging-services/proven-imaging/.

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