Appropriate Use Criteria Program
The Protecting Access to Medicare Act, passed by Congress in 2014, included a provision requiring all advanced diagnostic imaging services, excluding echocardiography, to undergo an appropriate use criteria (AUC) consultation prior to the completion of the imaging service in order to receive payment approval from the Centers for Medicare and Medicaid Services (CMS). In this provision, AUC are defined as evidence-based criteria that assist ordering professionals to make to the most appropriate treatment decisions for specific clinical conditions.
The AUC Program mandates that ordering professionals must consult with AUC through a clinical decision support mechanism (CDSM) for all Medicare patients receiving applicable advanced imaging care. In November 2017, CMS released the final 2018 Physician Fee Schedule (PFS), delaying the implementation of this consultation requirement, originally slated for Jan. 1, 2018, to begin Jan. 1, 2020. Coinciding with the release of the proposed PFS, CMS released an updated list of qualified CDSM vendors. In the coming months, CMS will propose and publish additional regulations and instructions on how ordering and imaging professionals are to participate in the AUC Program. The ACC is working to license its AUC content to qualified CDSMs. For a full list of those CDSMs, click here. Please note that the ACC's former FOCUS tool is not an approved CDSM.
Only AUC developed by entities meeting qualified "provider-led entity" (PLE) standards can be used. As a qualified PLE, the ACC is approved to develop and modify AUC for advanced diagnostic imaging through June 2021.