Everything You Need to know About CMS’ Appropriate Use Criteria Program

The New CMS Program is Now in Effect for 2022

The New Year always brings new provider regulations. It looks like 2022 is gearing up to be no different. We always strive to provide educational resources to better help practices and providers address changes to the regulatory environment. One major change coming in the New Year is CMS’ Appropriate Use Criteria Program (AUC). This will significantly impact your providers who order advanced diagnostic imaging services for their CMS patients. The AUC program will go into effect on January 1, 2022.  

The Appropriate Use Criteria Program was established in 2014 after the passage of The Protecting Access to Medicare Act. This new program is meant to increase the rate of appropriate advanced diagnostic imaging services provided to Medicare beneficiaries. Advanced imaging services include: 

  • Computed Tomography (CT) 
  • Positron Emission Tomography (PET) 
  • Nuclear Medicine 
  • Magnetic Resonance Imaging (MRI) 

This means AUC consultations with qualified CDSMs must occur alongside the reporting of consultation information by the furnishing practitioner or facility claim for advanced diagnostic imaging services. Claims that do not append this information will not be paid by CMS. 

What are the Specifics of the Appropriate Use Criteria Program? 

Under the Appropriate Use Criteria Program, a practitioner who orders advanced diagnostic imaging services for a Medicare beneficiary under their care, as well as clinical staff acting under their direction, will be required to consult a qualified Clinical Decision Support Mechanism (CDSM). 

 A CDSM is an electronic portal where Appropriate Use Criteria is accessed. The CDSM is an interactive, electronic tool used in clinical environments that communicates AUC information in order for the practitioner to make the most appropriate treatment decision for a patient’s condition. CDSMs may be modules that are available through a certified EHR. A list of CDSMs (by name) and their respective codes can be found on the CMS website. The CDSM determines whether or not the practitioner’s order is in compliance with AUC or if the AUC consulted was not applicable.  

Beginning in 2022, every consultation must occur when the order for advanced imaging services is placed and that will be furnished in an appropriate setting and paid for with an approved payment system. Practitioners whose imaging ordering patterns are considered outliers by the AUC will be subject to prior authorization. CMS is still determining an outlier methodology and prior authorization is not yet available. 

Who is Affected by Appropriate Use? 

The Appropriate Use Criteria Program impacts all physicians and practitioners who order advanced diagnostic imaging services for Medicare beneficiaries. It also impacts all physicians and practitioners who furnish advanced diagnostic imaging services and whose claims are paid under the physician fee schedule, hospital outpatient prospective payment system, or ambulatory surgical payment system. Practitioners and facilities impacted by this include; 

  • A Physician’s Office 
  • Hospital Outpatient Department (including the ER) 
  • Ambulatory Surgical Center 
  • Independent Diagnostic Testing Facility 

Be sure to prepare yourself for the Appropriate Use Criteria Program before the end of the year. Not sure what to do? You may need a RevCycle partner to help guide decisions and actions in your billing operation to improve your outcomes. Talk to PRL! We can help your practice strengthen its workflow and bolster your financial performance. If this sounds like something your practice needs, please start a dialogue with us! 

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