Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging: 2020 Testing Period Officially Underway

Tackling processes and departmental integration requirements for AUC will be key this year.

The testing phase for the Appropriate Use Criteria (AUC) Program officially began on Jan. 1, 2020.

Being as there is a purely educational and operational testing period, physicians and practitioners will not be subject to any adverse payment implications of the program. However, this should not serve as an invitation to postpone the internal operational testing – preparation is imperative.

Beginning in January 2021, physicians and other healthcare professionals who order an advanced diagnostic imaging test (MRI, CT, PET, and nuclear medicine; does not include X-rays, ultrasounds, or fluoroscopy services) must consult with AUC using a qualified decision support mechanism (CDSM). Professionals who provide these tests will be required to register the ordering professional’s consultation of AUC to be paid for the service.

AUC links a specific clinical condition to presentation, services, and an assessment of the appropriateness of services. AUC’s evidence-based criteria for imaging is meant to assist clinicians in selecting the imaging study that is most likely to improve healthcare outcomes. These criteria are developed by or endorsed by professional societies in order to assist ordering professionals in making the most appropriate treatment decision for a specific clinical condition of a patient.

The AUC for advanced diagnostic imaging require integration into a patient’s clinical workflow. Clinical decision support mechanisms (CDSMs) are electronic portals a clinician can use during a patient’s workup, typically, integrated within the electronic health record (EHR). Qualified CDSMs communicate AUC information to ascertain the most appropriate treatment decision for a patient’s specific clinical condition. Essentially, the underlying goal for AUC is to ensure the effective use of technology to guide referring physicians to the appropriate imaging for patients. 

Providers will be required to use a qualified CDSM (certified as meeting Centers for Medicare & Medicaid Services/CMS requirements). If a provider does not follow AUC requirements and is discovered to have ordering patterns deemed as outliers, the law mandates that CMS require prior authorization. G-codes are required for every advanced imaging service, and claims with multiple G-codes “shall be’’ accepted.

It is important to note that there are numerous modifiers for potential use when submitting a CPT® code, most of which start with the letter M, with the exception of one Q modifier. The specific modifiers are listed in the CY 2020 Outpatient Prospective Payment System (OPPS) Final Rule.

Though 2020 is a testing period, on Jan. 1, 2021, the denial saga shall begin. This is a considerable change, under evaluation for several years, so taking advantage of 2020 as a testing period, while there is no impact on reimbursement, is crucial. AUC applies to physician offices, hospital outpatient departments (including the ED), ambulatory surgery centers, independent diagnostic testing facilities, and various other provider-led outpatient settings, and there is no indication that CMS will delay implementation any further.  

In order to sufficiently prepare for the implementation of AUC, the involvement of multiple departments will be required, such as IT, radiology, physician, and health information management (HIM),  just to name a few. As healthcare has integrated information into a single source form, there continue to be disparate systems. When evaluating the implementation and workflow, consider newly acquired organizations that may not be on the same IT platform; also, consider miscellaneous systems that are an integral part of this process. Many times, orders continue to be scanned, so consider how these should be integrated into the system. If organizations are undergoing the implementation of an EHR, there is an opportunity for a hardship exemption. Many organizations have made the decision to roll out one modality at a time in order to work out any kinks in the system. Regardless of modality, it may be advantageous to implement this change within the outpatient departments simultaneously.  

Time has a tendency to move quicker than one can imagine. Don’t get caught off-guard by delaying preparation for this change. There are a lot of moving parts involving many different departments that require attention.

One consequence of this change that cannot be overstated is the impact it will have on the method in which high-cost imaging is ordered and approved. This factor alone should prompt facilities to move quickly to get a head start in working out the human dynamics of this change.

Further updates to the AUC program are included in the CY 2019 PFS Final Rule (pages 59688-59701 and page 60074).

Questions regarding this program may be submitted to the CMS Imaging AUC resource box: ImagingAUC@cms.hhs.gov.

For a current list of qualified CDSMs, refer to the Clinical Decision Support Mechanisms webpage.

Programming Note:

Listen to Susan Gatehouse report this story live today during Talk Ten Tuesday, 10-10:30 a.m. EST.