Medicare Appropriate Use Criteria (AUC)
CMS.gov (Centers for Medicare and Medicaid Services) is now requiring the use of Appropriate Use Criteria (AUC) for all providers who order advanced diagnostic imaging services for Medicare Part B patients including MRI, CT, PET and Nuclear Medicine.
Medicare’s goal of implementing AUC is to ensure that the most appropriate tests are ordered for Medicare Part B patients moving forward. An “appropriate” procedure is one for which the expected health benefits exceed the expected health risks by a wide margin.
AUC itself is the criteria by which the CMS determines whether a diagnostic test has been ordered appropriately for patients. It is a rating scale from 1-10, with ratings of 4-10 being considered “appropriate” scores.
How to:
If you are ordering an MRI or CT scan from us for a patient covered under Medicare Part B, you must first consult a qualified CDSM before placing the order. It is possible that your EHR (Electronic Health Record) is already pulling this info in for you and linking to a qualified CDSM. Do keep a record of the DSN (Decision Support Number) and the Appropriateness Score, in case you need to refer back to that information.
If you are in the position of choosing which CDSM to reference, make note of which tool you consulted. When placing the order for the diagnostic imaging service, please indicate which CDSM tool you consulted and what consultation number you received, so that we can appropriately conduct the imaging study for the patient.
Additionally, you will need to submit the following to the furnishing provider:
- NPI (National Provider Identifier) of the Ordering Physician
- Modifier which gives the result of the CDSM consultation
- G-Code that indicates which CDSM tool was utilized
Resources:
Below are links to free CDSM tools, which were approved by Medicare. Please note, these sites may require you to create an account or schedule a free demo in order to complete an AUC consultation:
Frequently Asked Questions:
Who and what is AUC required for?
AUC is required for any practitioner who orders the following advanced diagnostic imaging services for patients covered under Medicare Part B:
- MRI (Magnetic resonance imaging)
- CT (Computed tomography)
- PET (Positron emission tomography)
- Nuclear Medicine
What is it?
The “Protecting Access to Medicare Act” (PAMA) law of 2014 established a new program to increase the affected rate of appropriate advanced diagnostic imaging services (AUC), which are provided to Medicare Part B beneficiaries. The affected imaging services include; Computed Tomography (CT), Positron Emission Tomography (PET), Nuclear Medicine, and Magnetic Resonance Imaging (MRI).
When does it start?
The program began with a testing period from January 1, 2020 to December 31, 2020; the program will be fully implemented on January 1, 2021. Referring physicians and staff must become familiar with Appropriate Use Criteria (AUC) and applicable Clinical Decision Support Mechanisms (CDSMs) now to ensure they are ready for the transition in 2021.
To access a FREE Medicare Appropriate Use Criteria mechanism tool, click here.
How does It work?
The practitioner or clinical staff member who orders the advanced imaging services must consult a qualified Clinical Decision Support Mechanisms (CDSM). CDSMs are electronic portals that enable practitioners to access AUC during the patient workup. The CDSM will provide the referring professional with a determination whether the order adheres to, or does not adhere to, AUC. Contact your EMR/EHR (Electronic Medical Record/Electronic Health Record) provider to find out if they have an interface or if they plan to interface with a CDSM. If not, a list of qualified CDSMs is available here.
Why should you do this?
This will be a mandatory program for all offering providers who serve Medicare Part B patients as of 2021. It is important to ensure all practitioners and staff have a strong understanding of the program before it is implemented.