Appropriate Use Criteria (AUC): New Medicare Imaging Rules Go Into Effect January 1, 2022

Beginning in 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.

When we use “you”, we are referring to physicians, other practitioners, and facilities ordering advanced diagnostic imaging services and/or furnishing Part B advanced diagnostic imaging services to Medicare beneficiaries and billing Medicare Administrative Contractors (MACs).

Advanced Diagnostic Imaging Services:

• Diagnostic magnetic resonance imaging,
• Computed tomography
• Nuclear medicine (including positron emission tomography)

Purpose:

• The purpose of the AUC program is to enable you to order the most appropriate test for your patient.
• The Centers for Medicare & Medicaid Services (CMS) will use data collected from the program to identify outlier ordering professionals who will become subject to prior authorization.

Definitions:

• Appropriate use criteria (AUC )is criteria only developed or endorsed by national professional medical specialty societies or other provider-led entities (PLEs), so ordering and furnishing professionals can make the most patient-appropriate treatment decision for the specific clinical condition. To the extent possible, criteria must be evidence based.
• A Provider-led entity (PLE) is a national professional medical specialty society or other organization that is comprised primarily of providers or practitioners who, either within the organization or outside of the organization, predominantly provide direct patient care. Once a PLE is qualified, the appropriate use criteria (AUC) developed, modified or endorsed by the entity are considered specified applicable AUC.
• A 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. Tools may be modules within or available through certified electronic health record (EHR) technology (as defined in Section 1848(o)(4) of the Act), private sector mechanisms independent from certified EHR technology, or those established by CMS.
• A furnishing professional is a physician (as defined in Section 1861(r) of the Act) or a practitioner described in Section 1842(b)(18)(C) of the Act who furnishes an applicable imaging service.
• An ordering professional is a physician (as defined in Section 1861(r) of the Act) or a practitioner described in Section 1842(b)(18)(C) of the Act who orders an applicable imaging service.
• Priority clinical areas are clinical conditions, diseases, or symptom complexes and associated imaging services CMS identifies through annual rulemaking and in consultation with stakeholders. These areas may be used in the determination of outlier ordering professionals.

Currently, the program is set to be fully implemented on January 1, 2022, which means 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.

To completely understand these new Medicare imaging rules that go into effect on January 1, 2022, CME Online will be hosting an online meeting on June 5th.  Go to this link to register.

Michael G. Warshaw, DPM, CPC

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