What is the Appropriate Use Criteria Program & Why It Matters

October 24, 2020 | Article

By Dyan Torgerson, RHIT, CCS

The appropriate use criteria (AUC) program was established by the Protecting Access to Medicare Act (PAMA) of 2014, Section 218(b). The purpose of the program is to help providers ensure they order the most appropriate tests for their Medicare patients by consulting a Clinical Decision Support Mechanism (CDSM).

Currently this program is in a voluntary period, which began July 1, 2018, with an Education and Operations Testing Period starting January 1, 2020. Claims without AUC information will not be denied during this period; however, reporting is encouraged to allow CMS to track this information.

The AUC program was set to begin January 1, 2021. However, Medicare extended the Education and Operations Testing Period through calendar year 2021. Full implementation is set for January 1, 2022. The extension of the testing period gives providers more time to learn, test and prepare for the AUC program. For additional information please visit the Medicare Appropriate Use Criteria Program website.

Who is Affected by the AUC Program?
All providers who order advanced diagnostic imaging services that would be furnished in an applicable setting and paid under an applicable payment system (physician fee schedule, hospital outpatient prospective payment system, ambulatory surgical center payment system, etc.) will need to consult a CDSM to make patient-appropriate treatment decisions for the specific clinical condition.

Advanced diagnostic imaging includes:

  • Computed tomography
  • Positron emission tomography
  • Nuclear medicine
  • Magnetic resonance imaging

The consultation information must be provided to the furnishing provider and facility from the ordering provider. The following information must be included on the claim:

  • The ordering provider’s NPI
  • Which CDSM was consulted
  • Whether the service ordered would or would not adhere to the consulted AUC or whether consulted AUC was not applicable to the service ordered

What Challenges Will Hospitals, Including Critical Access Hospitals, Face?
While many settings will be affected, they are some challenges that are specific to critical access hospitals. As of now, critical access hospitals (CAHs) are exempt from reporting AUC information when furnishing an advanced diagnostic imaging service as they are not paid under an applicable payment system. This may apply when the CAH has elected Method II.

However, per a CMS open door forum, if the service is provided outside of the CAH then AUC information will need to be provided, and it is the ordering provider’s responsibility to provide that information. What happens when the CAH has not elected Method II and the reading radiologist is paid under an applicable payment system? This still needs to be clarified by CMS. However, we believe even if the radiologist is billing on an applicable payment system, the technical portion was performed in a CAH and the radiologist would therefore also be exempt. We anticipate a modifier will be created to show the radiologist is exempt from reporting AUC information.

Running your critical access hospital effectively has never been more important.


How Can I be Prepared to Implement the AUC Changes?
Be sure your organization is ready by contacting your EHR vendor to make sure there is a Medicare-approved CDSM incorporated into the software. If not, explore other standalone options available. Also, communicate to all ordering and rendering providers about the AUC program, how it will affect workflow and the importance of compliance with the program.

The AUC program will impact many health systems.

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