CMS has Delayed Implementation of Appropriate Use Criteria

Last week, CMS announced the Appropriate Use Criteria (AUC) testing period would be extended through calendar year 2021. CMS stated that there will be no payment consequences during the testing period. Currently, the program is set to be fully implemented on January 1, 2022, at which time payment consequences will go into effect. This extension came after serious lobbying from the American Hospital Association, American Medical Association, as well as, numerous other specialty organizations.

The AUC program will require providers who order advanced diagnostic imaging for Medicare patients such as CT, MRI, and PET to consult a qualified Clinical Decision Support Mechanism (CDSM) prior to officially ordering the imaging test.  It is important to note that while providers are required to consult the clinical decision tool, they are not required to follow the tool’s recommendations. 

CMS has stated the purpose of the AUC program is to verify medical necessity for advanced imaging, before a provider orders the service, in order to avoid unnecessary testing. However, there is wide spread concern among ordering providers that CMS is attempting to replace physician judgment.  There is an even bigger concern among the radiologists, who will be penalized, if the ordering physician does not consult the clinical decision tool.  Under the AUC program, payment for the radiologist’s interpretation will be denied if the ordering physician did not consult the Medicare CDSM prior to ordering services. 

Providers should take advantage of the implementation delay and use the additional time to:

  • Conduct vendor and EHR testing
  • Evaluate the policies, procedures and processes related to the ordering and performance of advanced imaging
  • Conduct provider and staff training.  

CMS has published a variety of AUC resources on their website.

HBE’s team of coding and compliance experts is available to assist you with evaluating your processes, review and development of policies and procedures, as well as providing customized education and training for your staff. 

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