Are you ready for Appropriate Use Criteria Program implementation?

The 2014 Protecting Access to Medicare Act included a provision requiring clinicians consult with appropriate use criteria (AUC) through a qualified clinical decision support mechanism (CDSM) when ordering advanced imaging services (i.e., SPECT/PET MPI, CT and MR) in order to receive payment approval from the Centers for Medicare and Medicaid Services (CMS). Following several delays, the implementation of this requirement has again been delayed beyond the end of the PHE. While not addressed in the recent CY 2023 physician fee schedule proposed rule, CMS posted a notice on the AUC Program site indicating the penalty phase will not begin January 1, 2023. The notice also states it is unknown when the penalty phase will begin.

Key Takeaways:

  • CMS will not deny claims that incorrectly report AUC information until some point beyond 2022 and the PHE, as part of an Educational and Operations Testing Period to allow providers to "learn, test and prepare."
  • Jan. 1, 2023, or the January 1 following the declared end of the PHE, marks the beginning of required reporting.
  • Only entities meeting qualified "provider-led entity" standards, like the ACC, can develop AUC for use in the program.
  • AUC consultation through a CDSM has been designated as an Improvement Activity under the Merit-Based Incentive Payment System, part of the Quality Payment Program.
  • Provisions included in the 2019 Medicare Physician Fee Schedule:
    • Require the use of forthcoming Healthcare Common Procedure Coding System G-codes and modifiers to report required AUC information on Medicare claims for both the technical and professional components;
    • Allow the delegation of AUC consultation with a qualified CDSM to clinical staff working under the direction of the ordering professional;
    • And revise the significant hardship criteria to include insufficient internet access, electronic health record or CDSM vendor issues, or extreme and uncontrollable circumstances.
  • The ACC continues to license its AUC content to qualified CDSM vendors. View a full list of ACC's CDSM partners.
  • Cardiovascular professionals should be holding planning discussions with their practice, cardiovascular business line and health systems to understand which AUC content and decision support vendors are, or will be, used.

Additional Resources: