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Are you ready for Medicare’s Appropriate Use Criteria program?

| January 6, 2020

Are you ready for Medicare’s Appropriate Use Criteria program?

If you order and/or provide CTs or other advanced imaging for your patients, keep in mind that Jan. 1 began the testing period for the start of Medicare’s mandatory Appropriate Use Criteria (AUC) program. Under this program, physicians who order advanced imaging services (CT, PET, MRI and Nuclear Medicine) will be required to consult an approved Clinical Decision Support Mechanism (CDSM). The AUC program was authorized by Congress to reduce unnecessary imaging services.

During the 2020 testing period, claims will not be denied for failing to use AUC-related information, but participation is encouraged. However, beginning in Jan. 2021, this information will be required on all Medicare claims for advanced diagnostic imaging. Failure to include it will result in claims denial unless an exception applies.

There are three exceptions to consulting a CDSM:

  • The ordering professional has a significant hardship defined as insufficient internet access, EHR or CDSM vendor issues or extreme and uncontrollable circumstances.
  • Emergency services were provided to individuals with emergency medical conditions.
  • Payment is made under Medicare Part A for an inpatient.

If no exception applies, the ordering provider must consult a CDSM and must report, through a modifier, whether the order adheres to AUC or, in some cases, that there is no AUC applicable to the patient’s clinical condition after the CDSM was consulted. Starting in Jan. 2021, the Center for Medicare and Medicaid Services (CMS) will begin collecting at least two years of AUC data from providers. It will use data to identify ordering professionals to subject to prior authorization requirements. The CMS website provides a list of approved CDSMs.

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