July 14, 2022

CMS Further Delays Imaging Appropriate Use Criteria Program

The Centers for Medicare and Medicaid Services (CMS) announced July 7 another delay in the implementation of the payment penalty phase of the appropriate use criteria (AUC) consultation mandate for Medicare advanced diagnostic imaging services. The announcement states that CMS is “unable to forecast when the payment penalty phase will begin.”

The mandate, which requires providers who order advanced diagnostic imaging services to consult a qualified clinical decision support mechanism containing AUC developed by qualified provider-led entities, passed as part of the Protecting Access to Medicare Act of 2014 (PAMA) as an alternative to prior authorization. In the payment penalty phase, a claim will be denied if the imaging provider fails to include required AUC consultation information provided by the ordering professional on applicable Part B claims.

The 2022 Medicare Physician Fee Schedule final rule established a penalty phase start date of Jan. 1, 2023, or the Jan. 1 following the end of the COVID-19 public health emergency. The recent website announcement indicates that the penalty phase will not begin on Jan. 1, 2023, even if the emergency ends in 2022. The PAMA AUC program was not discussed in the 2023 Medicare Physician Fee Schedule Proposed Rule.

The American College of Radiology® will continue to work with CMS to solve the logistical issues preventing full implementation of this important quality program that will ensure Medicare patients receive the right imaging at the right time. Questions about the PAMA AUC program may be directed to PAMA-AUC@acr.org.