Appropriate Use Criteria (AUC) is an evidence-based set of standards that are designed to assist professionals with decisions regarding appropriate treatment for patients with specific conditions. Included with the passage of the “Protecting Access to Medicare Act of 2014” (PAMA), was an appropriate use criteria program that includes advanced diagnostic imaging services (MRI, CT, and nuclear medicine).

Under the law, effective January 1, 2017, physicians who order these tests must consult with AUC, and physicians who perform these tests must provide documentation that confirms the ordering physician’s AUC adherence in order to be paid for the service.

AUC Timeline

The CY 2016 Medicare Physician Fee Schedule Final Rule identifies the components of the AUC plan as:

• Establishment of AUC by November 15, 2015
• Specification of clinical decision support mechanisms (CDS) for consultation with AUC by April 1, 2016
• AUC consultation by ordering professionals and reporting on AUC consultation by furnishing professionals by January 1, 2017
• Annual identification of outlier ordering professionals for services furnished after January 1, 2017.

Further clarification, and the process by which the CDS mechanisms will be specified, will be released by CMS after the CY 2017 final rule. Additional discussion and adopting policies regarding claims-based reporting requirements will also be included in both the CY 2017 and CY 2018 rules, which negatively impacts the likelihood that ordering and furnishing professionals will be expected to meet the program requirements by the January 1, 2017 deadline.

Establishing AUC

The establishment and finalization of AUC will be driven by local provider led-entities (PLE). The process by which a PLE is considered qualified by Medicare will be outlined in the final rule. These organizations will have the ability and the authority to develop, modify or endorse the criteria of other qualified PLEs, effectively lending itself to the creation of a larger, more clinically encompassing library.

Looking Ahead

Effective January 1, 2020, a prior authorization requirement for outlier professionals will be implemented. The final rule did not address this implementation, but CMS did propose to “identify outlier ordering professionals from within priority clinical areas that would be established through subsequent rulemaking.”

Considering the recommendation of the Medicare Evidence Development & Coverage Advisory Committee, The proposed list of priority clinical areas will be detailed in the CY 2017 PFS.

Learn more about Appropriate Use Criteria at the ASNC website and follow the Digirad blog for ongoing developments as they relate to imaging. Click here to read the full article.