(Aug. 14, 2020) – The Protecting Access to Medicare Act of 2014 established the Appropriate Use Criteria to ensure that appropriate advanced diagnostic imaging services (specifically, MRI, CT, PET and nuclear medicine) were being provided to Medicare beneficiaries. The AUC requires the ordering physician/professional use a Clinical Decision Support Mechanism to determine whether the advance diagnostic testing is appropriate. The AUC consultation information from the CDSM must be provided to the furnishing physician (i.e., radiologist) and the furnishing facility (outpatient prospective payment system hospitals, ambulatory surgery centers or independent diagnostic treatment facilities) and must be submitted on claims in order to receive reimbursement from the Medicare program. Critical Access Hospitals are exempt from the requirement of submitting AUC for advance diagnostic services performed in the CAH. However, ordering physicians that are employed by the CAH or the rural health clinic, will need to use the CDSM to provide the AUC to the furnishing physician/profession and the furnishing facilities that are required to report the AUC.
The calendar year of 2020 is the Education and Operations Testing Period for AUC, during which claims would not be denied for failing to include proper AUC consultation information. AUC was set to be fully implemented on Jan. 1, 2021, which means that AUC information must be on the claim to receive payment from Medicare.
The AHA and American Medical Association sent a joint letter to the Centers for Medicare & Medicaid Services in July of 2020, stressing how the COVID-19 public health emergency resulted in reduced imaging services, adding financial strains and prohibiting providers from sufficiently engaging in the AUC program's preparatory steps. On Aug. 10, the Centers for Medicare & Medicaid Services posted information on their website indicating the AUC testing period was extended through calendar year 2021. This means the AUC program will not impact claims payment for diagnostic imaging services until Jan. 1, 2022, at the earliest.
CMS will be providing an announcement on AUC during the Aug. 19 Physicians, Nurses & Allied Health Professionals Open Door Forum.