What the Appropriate Use Mandate Delay Means for Imaging Providers

Appropriate Use Mandate Delay

Last month, the Centers for Medicare and Medicaid Services (CMS) announced that the Medicare Appropriate Use Criteria Program deadline had been extended yet again. Originally slated to take effect on January 1, 2021, the new deadline extends the start date by a full year.

The rules and reimbursement guidance was originally part of the Protecting Access to Medicare Act of 2014, and was created to reduce the number of unnecessary scans being ordered. The program has experienced an unsteady, six-year roll out that continues to hang over imaging providers.

The deadline has been moved in the past, so the delay was not a complete surprise, but the rules will still affect physicians who order imaging scans.

How The Appropriate Use Criteria Program Works

Under the law, physicians who order CT, MRI, PET, or Nuclear Imaging scans must consult with appropriate use criteria. Physicians who perform these tests must provide documentation that confirms the ordering physician’s AUC adherence to be paid for the service.

Referring providers are required to use a Clinical Decision Support Mechanism (CDSM) before ordering imaging services. A CDSM is an interactive, digital tool used by physicians that helps the user determine the most appropriate treatment for a patient. It runs the patients’ variables against a set of pre-determined guidelines to weigh the benefits and state if the recommended scan is suitable for the patient.

If the CDSM agrees with the clinician and says the imaging is necessary, Medicare will pay for the scan. If not, the claim will not be reimbursed. CMS certifies and provides codes for 19 different CDSM providers, and new providers are still being approved.

When Will the AUC Rules Go into Effect?

While the Appropriate Use Criteria program has continued to see delays, it is slated to be fully implemented on January 1, 2022. Starting on that date, procedures ordered without consulting a CDSM will not be reimbursed.

Because of the seemingly constant delays, it can feel like the AUC mandate will never be implemented, but that should not stop practices from preparing for its eventual arrival.

As with previous years, there is a chance for another delay later in 2021, but providers should monitor the situation closely. Practices will need time to evaluate CDSM options, purchase the software, train staff, and implement the system. Waiting until the last minute could have drastic consequences to reimbursement stating in 2022.


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