Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging furnished to Medicare beneficiaries.
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 furnished to Medicare beneficiaries. Examples of advanced imaging services include:
• Computed tomography
• Positron emission tomography
• Nuclear medicine
• Magnetic resonance imaging
Under this program, when an advanced imaging service is ordered for a Medicare beneficiary, the ordering professional will be required to consult a qualified Clinical Decision Support Mechanism (CDSM). A CDSM is an interactive, electronic tool for use by clinicians that communicates AUC information to the user and assists them in making the most appropriate treatment decision for a patient’s specific clinical condition during the patient’s workup. The CDSM will provide the ordering professional with a determination of whether that order adheres to AUC, does not adhere to AUC, or if there is no AUC applicable (for example, no AUC is available to address the patient’s clinical condition) in the CDSM consulted.
When this program is fully implemented at a future date, a consultation must take place for any applicable imaging service ordered by an ordering professional that would be furnished in an applicable setting and paid under an applicable payment system and information related to the consultation must be appended to claims.
Note: The applicable setting is where the imaging service is furnished, not the setting where the imaging service is ordered.
Applicable settings include:
• Physician offices
• Hospital outpatient departments (including emergency departments)
• Ambulatory Surgical Centers (ASCs)
• Independent diagnostic testing facilities
Applicable payment systems include:
• Physician Fee Schedule (PFS)
• Hospital Outpatient Prospective Payment System
• ASCs
Voluntary participation was established for this program from July 1, 2018, through December 31, 2019. CR 10481 discusses the voluntary participation period.
The related MLN article may be read at
This CR contains information related to the Educational and Operations Testing Period which is expected to last for one year (January 1, 2020 – December 31, 2020). Full program implementation is expected January 1, 2021. At that time, information regarding the ordering professional’s consultation with CDSM, or exception to such consultation, must be appended to the furnishing professional’s claim in order for that claim to be paid.
Exceptions to consulting CDSMs include:
• The ordering professional having a significant hardship
• Situations in which the patient has an emergency medical condition
• An applicable imaging service ordered for an inpatient and for which payment is made under Part A
For more information visit
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11268.pdf
