July 16, 2021

CMS Promotes Appropriate Use Criteria Program in Proposed 2022 Medicare Physician Fee Schedule

The Centers for Medicare and Medicaid Services (CMS) in its 2022 Medicare Physician Fee Schedule (MPFS) proposed rule touted the appropriate use criteria (AUC) program mandated by the Protecting Access to Medicare Act of 2014 (PAMA) as a valuable tool “to guard against overutilization, fraud, waste, or abuse.” CMS proposes that the program, designed to be an educational tool for providers who order advanced diagnostic imaging services, be fully implemented on Jan. 1, 2023, or the January 1 following the declared end of the COVID-19 public health emergency (PHE).

The PAMA statute requires referring providers billing under the MPFS, Hospital Outpatient Prospective Payment System, or Ambulatory Surgical Center Payment System to consult AUC when ordering advanced diagnostic imaging studies through a qualified clinical decision support mechanism (CDSM). The CDSM provides immediate feedback on the appropriateness of the test being ordered for that patient. The referring provider must provide the imaging provider with the name of the CDSM consulted and the result of the consultation (i.e., adhere, not adhere, or no applicable AUC found). This information then must be included on the radiology claim for the radiologist to be paid for the service.

The program is currently in an “educational and operations testing period” that began Jan. 1, 2020, through the end of 2022 due to the PHE. When the program is fully implemented and the payment penalty phase begins, applicable radiology claims that do not include AUC consultation information will be denied.

PAMA included a Jan. 1, 2017, start date for the AUC program. However, CMS had difficulty developing claims processing edits that would accurately flag claims required to include AUC consultation information. In addition, the COVID-19 PHE caused delays in provider implementation of CDSM protocols. The 2022 proposed rule addresses the outstanding claims processing issues and would allow providers to continue to use the “significant hardship exception” for delays due to the PHE once the program enters the penalty phase.

The American College of Radiology® has prepared a detailed summary of the AUC provisions of the 2022 MPFS proposed rule. Questions about the AUC program should be directed to PAMA-AUC@acr.org.