Appropriate Use Criteria Mandate (section 218 PAMA)

MEDICARE’S APPROPRIATE USE CRITERIA PROGRAM
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Appropriate Use Criteria for Advanced Diagnostic Imaging Services
 
The “Protecting Access to Medicare Act of 2014 (PAMA)” (P.L. 113-93) established an appropriate use criteria (AUC) program for advanced diagnostic imaging services provided to Medicare beneficiaries. Beginning with a testing phase in 2020, physicians and other health care professionals who order an advanced diagnostic imaging test must consult with AUC using a qualified decision support (CDS) mechanism. Professionals who furnish these tests must document the ordering professional’s consultation of AUC to be paid for the service. The law also directs the Centers for Medicare & Medicaid (CMS) to require prior authorization for ordering outlier professionals.
 
Summary of Provisions from the CY 2019 Medicare Physician Fee Schedule Final Rule: 
In the CY 2019 Medicare Physician Fee Schedule (PFS) final rule, CMS stated its intention to move forward with the forward with implementation in 2020, which will begin with a testing phase. This educational and testing year will allow CMS and the provider community to address the technical coding and billing questions that remain. During this period, CMS will not deny claims that do not contain the proper AUC consultation information. The identification of outlier professionals is delayed due to the education and testing year. However, CMS reiterated the following clinical priority areas to guide the identification of outliers:
  • 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
The CY 2019 final rule expanded the program to include independent diagnostic testing facilities (IDTFs) in the list of “applicable settings,” meaning that providers who furnish advanced diagnostic imaging in those settings will need to meet AUC Program requirements. CMS also clarified that the AUC consultation requirement applies to the facility portion (the technical component) of the imaging service.
 
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. 
 
Application of the Program:
 
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. 
 
Definitions:
 
AUC — AUC means criteria only developed or endorsed by national professional medical specialty societies or other provider-led entities, to assist ordering professionals and furnishing professionals in making the most appropriate treatment decision for a specific clinical condition for an individual. To the extent feasible, such criteria must be evidence-based. An AUC set is a collection of individual appropriate use criteria. An individual criterion is information presented in a manner that links: a specific clinical condition or presentation; one or more services; and, an assessment of the appropriateness of the service(s). 
 
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.