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). As a result of advocacy efforts to delay the official start of the program in light of COVID-19, CMS extended the Education and Testing period beyond 2022. The program will remain in an Education and Operations Testing phase during which CMS will not deny claims that incorrectly report AUC information. ACC is continuing to work with partner societies and other stakeholders to educate and prepare providers for the implementation of potentially significant changes to practice workflows resulting from the AUC Program.

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."
  • 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.
  • Key provisions include:
    • Healthcare Common Procedure Coding System G-codes and modifiers must be used to report required AUC information on Medicare claims for both the technical and professional components;
    • AUC consultation with a qualified CDSM can be delegated to clinical staff working under the direction of the ordering professional;
    • Insufficient internet access, electronic health record or CDSM vendor issues, or extreme and uncontrollable circumstances are eligible “Significant Hardship Criteria.”
  • The ACC continues to license its AUC content to qualified CDSM vendors. View a full list of ACC's CDSM partners. Access ACC’s licensing FAQ document.
  • 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: