Appropriate Use Criteria Program

Background

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 provided to Medicare beneficiaries. Examples of such advanced imaging services include:

• computed tomography (CT)
• positron emission tomography (PET)
• nuclear medicine, and
• magnetic resonance imaging (MRI)

Under this program, at the time a practitioner orders an advanced diagnostic imaging service for a Medicare beneficiary, he/she, or clinical staff acting under his/her direction, will be required to consult a qualified Clinical Decision Support Mechanism (CDSM). CDSMs are electronic portals through which appropriate use criteria (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). A consultation must take place at the time of the order for imaging services that will be furnished in one of the below settings and paid for under one of the below payment systems.  Ultimately, practitioners whose ordering patterns are considered outliers will be subject to prior authorization.  Information on outlier methodology and prior authorization is not yet available. 

This program impacts all physicians and practitioners (as defined in 1861(r) or described in 1842(b)(18)(C)), that order advanced diagnostic imaging services and physicians, practitioners and facilities that furnish advanced diagnostic imaging services in a physician’s office, hospital outpatient department (including the emergency department), an ambulatory surgical center or an independent diagnostic testing facility (IDTF) and whose claims are paid under the physician fee schedule, hospital outpatient prospective payment system or ambulatory surgical center payment system.

Program Timeline

As announced in the CY 2022 Physician Fee Schedule Final Rule, the program is set to be fully implemented on the later of January 1, 2023 or the January 1 that follows the declared end of the public health emergency (PHE) for COVID-19. At that time, 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.  Prior to this date the program will operate in an Education and Operations Testing Period starting January 1, 2020 during which claims will not be denied for failing to include proper AUC consultation information.  Beginning July 1, 2018 the program operated under a voluntary participation period during which time consultations with AUC that occured were reported on furnishing professional and facility claims using HCPCS modifier QQ.     

Rules and Regulations

These policies are codified in our regulations at 42 CFR 414.94.

The CY 2016 Physician Fee Schedule (PFS) Final Rule with Comment Period introduced this program (pages 71102-71116 and pages 71380-71382).

Additional policies related to this program are included in the CY 2017 PFS Final Rule (pages 80403-80428 and pages 80554-80555).

The CY 2018 PFS Final Rule includes requirements for consulting and reporting under the Medicare AUC program (pages 53187-53201 and page 53363).

Further updates to the AUC program are included in the CY 2019 PFS Final Rule (pages 59688-59701 and page 60074).

Further updates to the AUC program are included in the CY 2022 PFS Final Rule (pages 65224-65241)

Questions regarding this program may be submitted to the CMS Imaging AUC resource box: [email protected].