Centers for Medicare & Medicaid Implement New Criteria for Advanced Imaging

January 21, 2020

Beginning January 1, 2020, the Centers for Medicare & Medicaid Services (CMS) is implementing a new appropriate use criteria (AUC) program that will be applied to advanced diagnostic imaging services. The program was established as a provision of the 2014 Protecting Access to Medicare Act (PAMA) to reduce overutilization of these services.

Under the new AUC program, clinicians are required to consult a qualified Clinical Decision Support Mechanism (CDSM) prior to ordering Medicare Part B advanced diagnostic imaging services, defined as an MRI, CT, nuclear medicine, or PET scan. The ordering of ultrasound services is not included in this requirement. CMS defines a CDSM as “an interactive, electronic tool for use by clinicians that communicates AUC information to the user and assists them in making the most appropriate treatment decision for a patient’s specific clinical condition.” Clinicians will also be required to provide the AUC information to professionals and facilities furnishing advanced diagnostic imaging services to demonstrate that an AUC consultation occurred.

CMS implemented an initial voluntary testing period for the AUC program from July 1, 2018 – December 31, 2019. On January 1, 2020, the agency is beginning the educational and operations testing period for the AUC program, which will last one year, through December 31, 2020. During this phase, furnishing professionals will be required to report a code on their claims for advanced diagnostic imaging services.  CMS will not deny a claim that incorrectly reports AUC information during the education and operations testing period. Starting in 2021, however, advanced diagnostic imaging claims without the appropriate AUC coding information will be rejected.

CMS has identified the following eight priority clinical areas to initially review for overutilization and ordering patterns inconsistent with AUC:

  • Coronary artery disease (suspected or diagnosed)
  • Suspected pulmonary embolism
  • Headache (traumatic and non-traumatic)
  • Hip pain
  • Low back pain
  • Shoulder pain (including suspected rotator cuff injury)
  • Cancer of the lung (primary or metastatic, suspected or diagnosed)
  • Cervical or neck pain

The PAMA law requires CMS to collect AUC data in order to identify professionals whose ordering patterns are considered “outliers” and subject them to future prior authorization requirements. Once the program is fully implemented, the AUC consultation will be required for all advanced diagnostic imaging services, not just those provided within the priority clinical areas.

CMS will grant ordering clinicians exceptions to the AUC reporting requirements due to insufficient internet access, electronic health record or CDSM vendor issues, or extreme and uncontrollable circumstances. Exceptions may also be made when services are provided to patients with certain emergency medical conditions and to inpatients for which Medicare Part A payment is made.

For more information on the new Medicare AUC program, review the following fact sheet.