Appropriate Use Criteria Program
The Protecting Access to Medicare Act (PAMA) of 2014, Section 218(b), amended Section 1834(q) to establish the Appropriate Use Criteria (AUC) Program to increase the use of AUC for advanced diagnostic imaging services provided to Medicare beneficiaries.
Under this program, an AUC consult prior to ordering advanced diagnostic imaging (CT, MR, Nuclear Medicine and PET) for Medicare patients, must be documented via a Centers for Medicare and Medicaid Services (CMS) qualified clinical decision support mechanism (qCDSM).
A Clinical Decision Support Mechanism (CDSM) is an interactive, electronic tool for use by clinicians that communicates appropriate use criteria (AUC) information to the user and assists them in making the most appropriate treatment decision for a patient’s specific clinical condition. They may be modules within or available through certified electronic health record technology (CEHRT).
Without a documented consult, rendering providers (both facilities and radiologists) will not receive Medicare payment for the procedure.
AUC for Advanced Diagnostic Imaging
CMS finalized an Education and Operations Testing Period, that will run from January 1, 2020 through December 31, 2021, where there will be no penalties for incorrect reporting.
Effective January 1, 2022, if you order Medicare Part B advanced diagnostic imaging services, you must consult appropriate use criteria (AUC) through a qualified Clinical Decision Support Mechanism (CDSM). You must also provide the information to furnishing professionals and facilities, because they must report AUC consultation information on their Medicare claims.
Ordering providers are required to consult AUC for all Medicare Part B Advanced Diagnostic Imaging Services. Consultation is required in all applicable settings as outlined by CMS. These include physician offices, hospital outpatient departments (including emergency departments), ambulatory surgical centers, and independent diagnostic testing facilities.