Section 218(b) of the Protecting Access to Medicare Act of 2014 directed the Centers for Medicare and Medicaid Services (CMS) to establish a program to promote consultation of appropriate use criteria (AUC) by ordering physicians prior to referring Medicare beneficiaries for advanced diagnostic imaging services beginning on January 1, 2017. AUC are defined as criteria that are evidence-based (to the extent feasible) and assist professionals who order and furnish applicable imaging services to make the most appropriate treatment decisions for a specific clinical condition.
While the statutory language mandated an effective date of January 1, 2017, the timing of the rulemaking process used by CMS made it extremely difficult to achieve this implementation date. In the 2017 Medicare Physician Fee Schedule (MPFS) final rule, CMS indicated that they continue to aggressively move forward to implement this AUC program. The first qualified clinical decision support mechanisms (CDSMs) were announced on June 30, 2017. CMS announced in the 2018 Medicare Physician Fee Schedule final rule that furnishing professionals will begin reporting AUC consultation on January 1, 2020.
The statute requires the identification of outlier ordering professionals. Once CMS has collected two years of ordering data, providers identified as ordering outliers will be subject to a prior authorization requirement. The list of priority clinical areas will serve as the basis for identifying outlier ordering professionals.
The final list of priority clinical areas includes the following clinical conditions:
Future MPFS rules are expected to provide further clarity behind the concept of “prior authorization.”
Consulting and reporting requirements are not required for orders for applicable imaging services made by ordering professionals under the following circumstances:
The CY 2017 MPFS Final Rule addresses the emergency medical condition exemption. CMS indicates while they acknowledge that most of these exempt emergent situations will occur primarily in the emergency department, these situations may arise in other settings as well. Further, they recognize that most encounters in the ED are NOT for an emergency medical condition.
The rule states, "To meet the exception for an emergency medical condition, the clinician only needs to determine that the medical condition manifests itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in: placing the health of the individual (or a woman's unborn child) in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part." In future rulemaking, CMS will detail how this exception will be indicated on the Medicare claim.