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:

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.

Print Friendly, PDF & Email

Susan Gatehouse, RHIT, CCS,CPC, AHIMA-Approved ICD-10-CM/PCS Trainer

Susan Gatehouse is the founder and chief executive officer of Axea Solutions. An industry expert in revenue cycle management, Gatehouse established Axea Solutions in 1998, and currently partners with healthcare organizations across the nation, to craft solutions for unique challenges in the dynamic world of healthcare reimbursement and data management.

Related Stories

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

2024 Observation Services Billing: How to Get It Right

2024 Observation Services Billing: How to Get It Right

Dr. Ronald Hirsch presents an essential “A to Z” review of Observation, including proper use for Medicare, Medicare Advantage, and commercial payers. He addresses the correct use of Observation in medical patients and surgical patients, and how to deal with the billing of unnecessary Observation services, professional fee billing, and more.

March 21, 2024
Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets

Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets

Explore the top-10 federal audit targets for 2024 in our webcast, “Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets,” featuring Certified Compliance Officer Michael G. Calahan, PA, MBA. Gain insights and best practices to proactively address risks, enhance compliance, and ensure financial well-being for your healthcare facility or practice. Join us for a comprehensive guide to successfully navigating the federal audit landscape.

February 22, 2024
Mastering Healthcare Refunds: Navigating Compliance with Confidence

Mastering Healthcare Refunds: Navigating Compliance with Confidence

Join healthcare attorney David Glaser, as he debunks refund myths, clarifies compliance essentials, and empowers healthcare professionals to safeguard facility finances. Uncover the secrets behind when to refund and why it matters. Don’t miss this crucial insight into strategic refund management.

February 29, 2024
Mastering Medicare Notices: Your Essential Guide to the MOON and Beyond

Mastering Medicare Notices: Your Essential Guide to the MOON and Beyond

Hospital staff continue to grapple with the complexities of Medicare notices.  In this webcast, Tiffany Ferguson, LMSW, CMAC, ACM, will present the latest requirements for preparation and delivery of CMS-mandated forms, including the Advance Beneficiary Notice (ABN), Hospital-Issued Notices of Noncoverage (HINNs), Important Message from Medicare (IMM) and Medicare Outpatient Observation Notice (MOON), and practical solutions through foolproof workflows and compliance auditing.

January 25, 2024
OBGYN ICD-10-CM/PCS Coding: Mastering Complex Guidelines and Compliance

OBGYN ICD-10-CM/PCS Coding: Mastering Complex Guidelines and Compliance

Dive into the complexities of Obstetrics and Gynecology coding, addressing challenges from antepartum to postpartum care. Learn to decode intricate guidelines, tackle claim denials, and safeguard your practice’s financial health. Uncover the secrets to compliant coding, reducing errors, and optimizing reimbursement. With practical exercises and expert insights, this webcast empowers coders, auditors, and healthcare professionals to elevate their OBGYN coding prowess.

February 28, 2024
Unlocking Clinical Documentation Excellence: Empowering CDISs & Coders

Unlocking Clinical Documentation Excellence: How to Engage the Provider

Uncover effective techniques to foster provider understanding of CDI, empower CDISs and coders to customize their queries for enhanced effectiveness, and learn to engage adult learners, leveraging their experiences for superior learning outcomes. Elevate your CDI expertise, leading to fewer coding errors, reduced claim denials, and minimized audit issues.

December 14, 2023
Coding for Spinal Procedures: A 2-Part Webcast Series

Coding for Spinal Procedures: A 2-Part Webcast Series

This exclusive ICD10monitor webcast series will help you acquire the critical knowledge you need to completely and accurately assign ICD-10-PCS and CPT® codes for spinal fusion and other common spinal procedures.

October 26, 2023

Trending News

It’s Heart Month! Use code HEART24 at checkout to receive 20% off your cardiology products. Click here to view our suite of Cardiology products!