Appropriate Use Criteria Mandate (section 218 PAMA)
MEDICARE’S APPROPRIATE USE CRITERIA PROGRAM
ASNC, Other Organizations Thank Rep. Tim Ryan for Leadership on Medicare AUC Program - Sept. 17, 2021
ASNC, Other Organizations Thank Reps. Rosa DeLauro and Kay Granger for Leadership on Medicare AUC Program - Sept. 17, 2021
- Updated Look at AUC Program
- AUC Program at a Glance
- ASNC CY2017 PFS Comment Letter
- CMS's designated Provider Led Entities
- Proposed Clinical Priority Areas
- ASNC, Multi-Speciality Coalition Successful as AMA HOD voted to adopt AUC Program Resolution
- CY2020 Fact Sheet on the Medicare PFS proposed rule
- CY2020 Medicare PFS proposed rule in its entirety
- CY2020 Fact Sheet on the Hospital OPPS proposed rule
- CY2020 Hospital OPPS proposed rule in its entirety
- CY2018 Proposed Rule AUC Provisions
- Fact Sheet on the Medicare PFS final rule
- Medicare PFS final rule in its entirety
- Fact Sheet on the Hospital OPPS final rule
- Hospital OPPS final rule in its entirety
Appropriate Use Criteria for Advanced Diagnostic Imaging Services
- Coronary artery disease (suspected or diagnosed)
- Suspected pulmonary embolism
- Headache (traumatic and non-traumatic)
- Hip pain
- Low back pain
- Shoulder pain (to include suspected rotator cuff injury)
- Cancer of the lung (primary or metastatic, suspected or diagnosed) and
- Cervical or neck pain
CMS finalized that AUC data will be reported by furnishing professionals on the Medicare claim form using a series of G codes and modifiers — a proposal CMS previously abandoned. CMS acknowledged that the use of G-codes and modifiers may not be an ideal solution for reporting AUC data. CMS also noted there are still technical issues that will need to be worked out with regard to G-codes. CMS has yet to propose how the transfer of AUC information will occur between the ordering and furnishing professions, nor precisely how it will identify outlier ordering professionals who will be subject to prior authorization.
The program only applies to “applicable imaging services” which are defined in law as advanced diagnostic imaging services for which one or more applicable AUC apply, one or more CDS mechanisms is available, and one of those mechanisms is free of charge.
Provider-Led Entity — AUC become specified when they are developed or modified by a qualified PLE, or when a qualified PLE endorses AUC developed by another qualified PLE. Therefore, the definition of PLE is critical to the program.
CMS initially proposed a definition of PLE that explicitly included national professional medical specialty societies, as well as organizations comprised primarily of providers and actively engaged in the practice and delivery of health care. In its rulemaking process, CMS revised the definition of a PLE to refer to organizations “comprised primarily of providers or practitioners who, either within the organization or outside of the organization, predominantly provide direct patient care. The definition of PLE will retain the direct reference to national professional medical societies and other organizations like them are subsumed within the definition.
Conflicting AUC — CMS acknowledges that conflicting AUC maybe be a concern, but generally believes that qualified PLEs will be using an evidence-based AUC development process that will reduce the likelihood and frequency of conflicting AUC. CMS states that in some situations it may be appropriate for CMS and MEDCAC to review the evidence base.