December 14, 2017

CMS Moves Forward With AUC Mandate in 2018 MPFS Final Rule

CMS recognized the importance of appropriate use criteria for diagnostic imaging by physicians who order and furnish the services as a qualifying high-weighted improvement activity.
On Nov. 2, 2017, the Centers for Medicare and Medicaid Services (CMS) released the 2018 Medicare Physician Fee Schedule (MPFS) Final Rule. Of particular interest to radiology is recognition by CMS of the importance of the use of appropriate use criteria (AUC) for diagnostic imaging by physicians who order and furnish the services as a qualifying high-weighted improvement activity if they attest they are using AUC through a qualified clinical decision support mechanism (CDSM) for all advanced diagnostic imaging services ordered.

Implementation Date: Jan. 1, 2020

In the proposed rule comments, stakeholders expressed concerns about the readiness to implement the AUC program by the proposed Jan. 1, 2019 date. CMS was asked to delay AUC program implementation until after implementation of the Quality Payment Program (QPP). In the final rule, CMS further delayed the start of the AUC program until Jan. 1, 2020, to allow providers more time to prepare for implementation.

On Jan. 1, 2020, the program will begin with an educational and operations testing period. During this time, CMS will continue to pay claims whether or not they correctly include such information. Ordering professionals must consult specified AUC through qualified CDSMs for applicable advanced diagnostic imaging services furnished in an applicable setting, paid for under an applicable payment system, and ordered on or after Jan. 1, 2020. Furnishing professionals must report the AUC consultation information on the Medicare claim for these services ordered on or after Jan. 1, 2020.

The agency is also finalizing a voluntary reporting period where early adopters can begin to report some consultation information on Medicare claims from July 2018 through Dec. 2019.

Claims Processing

CMS agreed that a less burdensome approach to claims reporting should be considered. The agency will not develop the G-code and modifier approach and will further pursue use of the unique consultation identifier for reporting on Medicare claims. CMS will conduct stakeholder outreach during 2018 to develop a standard taxonomy ahead of the 2020 effective date. CMS does expect that limited use of modifiers will be required in the future to identify exceptions to AUC consultation requirements.

Hardship Exceptions

CMS decided not to finalize proposed changes to the significant hardship exceptions in this final rule. The agency will take time to consider both the public comments on the proposals and the policies adopted in the CY 2018 QPP final rule and will revisit the issue in rulemaking for CY 2019. Examples of hardship exceptions under consideration include:

  • Imaging services ordered as part of clinical research
  • Emergency clinicians attempting to meet the current exclusion criteria
  • Physicians nearing retirement or dealing with hardships who can’t invest in a qualified CDSM
  • Physicians who do not have access to free integrated CDSMs or whose EHR cannot integrate into an existing qualified registry