Commencing Jan. 1, 2020 the Protecting Access to Medicare Act (PAMA) requires referring providers to consult Appropriate Use Criteria (AUC) prior to ordering Advanced Diagnostic Imaging Services (ADIS), CT, MR, Nuclear Medicine and PET, for Medicare patients.
The Appropriate Use Criteria will apply to services furnished in a hospital outpatient department, physician’s office, or an ambulatory surgery center. Prior to ordering diagnostic imaging services for Medicare Part B patients, those providing these services will consult with a Clinical Decision Support Mechanism (CDSM).
According to Robert Tennant, MA, Director of Health Information Technology Policy for MGMA’s government advocacy, CMS has been testing the program with voluntary participation and will start an educational and operational testing period next year. Full implementation of the program will occur in January 2021.
The rule applies to advance imaging services such as:
- Nuclear medicine
The CDSM determines whether the order adheres to the AUC, or if the AUC consulted was not applicable (e.g., no AUC is available to address the patient’s clinical condition).
A CDSM is an interactive, electronic tool for use by clinicians. The CDSM communicates the AUC information and assists users in making the most appropriate treatment decision for a patient’s specific clinical condition.
Initially, the AUC program will require health professionals to report a code on their claims (QQ) for advanced diagnostic imaging services covered by the program. This includes diagnostic magnetic resonance imaging, computed tomography, nuclear medicine and positron emission tomography. Beginning in 2021, claims submitted without a code will be rejected.
Throughout the 2020 calendar year, CMS will not require the AUC consultation code on advanced imaging orders. The AUC consultation code on will also not be required on Medicare claims. However, beginning January 2021, an AUC consultation must take place at the time imaging services are ordered. The order will be furnished in one of the designated settings and paid for under one of the designated payment systems including the physician fee schedule, outpatient prospective payment system and ambulatory surgical center payment system.
Qualified Clinical Decision Support Mechanisms as of June 2019
- AgileMD’s Clinical Decision Support Mechanism
- AIM Specialty Health ProviderPortal®*
- Applied Pathways CURION™ Platform
- Cranberry Peak ezCDS
- eviCore Healthcare’s Clinical Decision Support Mechanism
- EvidenceCare’s Imaging Advisor Inveni-QA’s Semantic Answers in Medicine™
- MedCurrent OrderWiseTM
- Medicalis Clinical Decision Support Mechanism
- National Decision Support Company CareSelect™*
- National Imaging Associates RadMD
- Reliant Medical Group CDSM
- Sage Health Management Solutions Inc. RadWise®
- Stanson Health’s Stanson CDS
- Test Appropriate CDSM*
Questions regarding this program may be submitted to the CMS Imaging AUC resource box at ImagingAUC@cms.hhs.gov.
Presentation from ACR: