Like many other things during the public health emergency (PHE) due to the COVID pandemic, the AUC program which was to be fully implemented by Medicare on 1/1/21 has been delayed. The new mandatory implementation date is 1/1/22.
“Wait, what is the AUC?” you ask!
The Center for Medicare & Medicaid Services (CMS) established a new program, mandatory effective 1/1/21, requiring that physicians who order advanced imaging services seek to comply with appropriate use criteria for Medicare beneficiaries; if they do not, the physician may ultimately be required to have those services prior authorized. Examples of such advanced imaging services include:
- computed tomography (CT)
- positron emission tomography (PET)
- nuclear medicine, and
- magnetic resonance imaging (MRI)
CMS will require the ordering physician (or his/her designed such as clinical staff) to consult a qualified Clinical Decision Support Mechanism (CDSM). CDSMs are electronic portals through which appropriate use criteria (AUC) are accessed. The CDSM provides a determination of whether the provider’s order adheres to AUC, or if the AUC consulted was not applicable (e.g., no AUC is available to address the patient’s clinical condition). An AUC consultation must take place in order for payment to occur unless an exception is granted.
Why is CMS doing this? Well, “Ultimately, practitioners whose ordering patterns are considered outliers will be subject to prior authorization” according to the CMS AUC website.
The Education and Operations Testing period, or option consulting of a CDSM, has been extended through CY 2021. Stay tuned with KZA for more information later in 2021 for how to implement this in your practice!
For more information on the CMS AUC program visit the website.
