*** Edit: AUC is now set to begin January 1, 2023***
After being delayed several times the CMS Appropriate Use Criteria or AUC program will officially begin on Jan. 1, 2022. This will have significant operational and financial impacts on your practice.
As of January 1st, 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 or qCDSM. You must also provide the information to furnishing professionals and facilities, because they must report AUC consultation information on their Medicare claims.
Any claims submitted to CMS for Advanced Radiology Procedures (CT, MRI, Nuclear Medicine and PET Scan) will have to include proof of consultation with a CMS approved Clinical Decision Support Mechanism, otherwise those claims will not be paid by CMS.
AUC - A set of standards developed by medical professional specialty societies and other provider-led entities so that ordering and furnishing providers can make patient appropriate, evidence based treatment decisions.
CDSM - is an interactive, electronic tool for clinicians that gives the user AUC information. You can use this information to make the most patient-appropriate treatment decision for the specific clinical condition. Typically this information is evidence based.
Furnishing professional - Physician or a practitioner who furnishes an applicable imaging service.
Ordering professional- Physician or a practitioner who orders an applicable imaging service.
What is the Appropriate Use Criteria Program?
The Protecting Access to Medicare Act (PAMA) of 2014 established the Appropriate Use Criteria (AUC) Program to increase the rate of appropriate advanced diagnostic imaging services provided to Medicare Part B beneficiaries. Examples of such advanced diagnostic imaging services include:
- Computed tomography (CT)
- Positron emission tomography (PET)
- Nuclear medicine
- Magnetic resonance imaging (MRI)
What’s Required by the Practice?
At the time a provider orders an advanced diagnostic imaging service for a Medicare Part B beneficiary, the ordering provider or their clinical staff proxy will be required to consult a qualified Clinical Decision Support Mechanism (CDSM). CDSMs are electronic portals through which AUC is accessed. 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). The ordering provider then needs to give the furnishing provider the results of the AUC.
For complete information, refer to CMS's Appropriate Use Criteria Program webpage.
When does the AUC program start?
Starting January 1, 2022, AUC consultations with qualified CDSMs are required to occur along with reporting of consultation information on the furnishing professional and furnishing facility claim for the advanced diagnostic imaging service. Claims that fail to append this information will not be paid.
CY 2021 is an educational and operations testing period (extended from CY 2020). Providers should this time to learn and test for the AUC program. Claims will NOT be denied for failing to include AUC consultation information during 2021.
Medicare has identified high-priority areas for CDSMs to focus on for under or over utilization of diagnostics. They include the following:
- Coronary artery disease
- Suspected pulmonary embolism
- Hip pain
- Low back pain
- Shoulder pain
- Cancer of the lung (primary or metastatic, suspected or diagnosed)
- Cervical or neck pain
Selecting a CDSM
It’s up to each practice to determine which CDSM to utilize. There are a host of CDSM providers that offer cloud based solutions, some free and others are available for a fee. For the most part these are stand-alone solutions, not integrated into an EHR or PM solution.
The optimal solution however would be a CDSM platform integrated into your EHR. Check with your EHR vendor now to see if they’ll be offering an integrated solution or if not fully integrated will they be partnering with a company to offer a third party solution.
SETTING AND PAYMENT FOR AUC CONSULTATION
An AUC consultation must occur for advanced diagnostic imaging services that are performed in a physician’s office, a hospital outpatient department (including an emergency department), an ambulatory surgical center, an independent diagnostic testing facility (IDTF) or any other provider-led outpatient setting CMS determines appropriate.
Claims from the professional and facility for advanced diagnostic imaging services furnished in these settings and paid by CMS using one of the following payment systems will be required to append AUC consultation information. The AUC consultation information must be provided to the furnishing professional and facility from the ordering professional. The setting the service is furnished in determines which payment system CMS uses to pay a properly documented claim for advanced diagnostic imaging services:
- Physician Fee Schedule
- Outpatient Prospective Payment System
- Ambulatory Surgical Center Payment System
Accurate CDSM Coding is the Key to Reimbursement
CMS announced HCPCS Modifiers and G Codes that have to be used to define CDSM and to modify CPT procedure codes. The HCPCS Modifiers relay the results of the consult and provide a unique consult identifier, while the G Codes define which CMS approved vendor was utilized.
There are some, limited exceptions to the AUC reporting requirements as follows:
- Emergency services, when provided to patients with certain emergency medical conditions (as defined in Section 1867(e)(1) of the Act)
- Inpatients and for which Medicare Part A payment is made
- Ordering professionals, when experiencing a significant hardship including:
- Insufficient internet access
- EHR or CDSM vendor issues
- Extreme and uncontrollable circumstances
With approximately 150 working days left until the Appropriate Use Criteria program is required, practices must act now to determine whether their existing EHR provides a CDSM or if they’ll need to find a 3rd party alternative.
Once you understand your options and choices you need to review the software workflow and understand how it will fit into your existing practice workflows. Once you do you can take steps to make any needed changes, perform staff training etc. so you’re fully prepared to deal with this challenge.