A program designed to push providers to consult for “appropriate use” of advanced diagnostic imaging services ordered for Medicare beneficiaries in order to avoid claim denials will not be enforced until 2022 instead of next year as initially proposed, according to a recent bulletin issued by CMS.
The Appropriate Use Criteria (AUC) Program moved to an “educational” trial phase this year after being created in 2016 under the Protecting Access to Medicare Act (PAMA). During this time, providers were encouraged to become familiar with the process in order to be prepared for implementation in 2021. They now have an additional year to get familiarized with the requirements before they are implemented on Jan. 1, 2022.
Under this program, when a provider orders an advanced diagnostic imaging service for a Medicare patients, they will be required to consult a qualified Clinical Decision Support Mechanism (CDSM), electronic portals that provide access to the applicable criteria and provides a determination of whether the order adheres to AUC, or if the AUC consulted was not applicable. A consultation must take place at the time of the order for imaging services.
Examples of applicable advanced imaging services include:
- Computed tomography (CT)
- Positron emission tomography (PET)
- Nuclear medicine, and
- Magnetic resonance imaging (MRI)
This impacts all providers who order advanced diagnostic imaging services and who furnish those services in a physician’s office, hospital outpatient department (including the emergency department), an ambulatory surgical center or an independent diagnostic testing facility and whose claims are paid under the physician fee schedule, hospital outpatient prospective payment system or ambulatory surgical center payment system.
Providers whose ordering patterns are considered outliers will be subject to prior authorization, or could see their claims denied altogether. Information on outlier methodology and prior authorization is not yet available.
More information on the program, including a list of impacted services, is available here.