Changes to Appropriate Use Criteria for Advanced Diagnostic Imaging
Starting January 1, CMS began testing the condition for Appropriate Use Criteria (AUC) requiring a qualified Clinical Decision Support Mechanism (CDSM) consultation by a qualified provider for payment on Advanced Diagnostic Imaging for Medicare beneficiaries. Claims must include the ordering professional’s NPI, which CDSM tool was utilized for the consultation, and “whether the service ordered would or would not adhere to consulted AUC or whether consulted AUC was not applicable to the service ordered” (CMS, 2018). The program will be fully implemented by January 1, 2021.
Diagnostic Advanced Imaging services include:
- CT scans
- Nuclear Medicine
- PET scans
AUC for these Advanced Diagnostic Imaging tests above are designed to assist the clinicians in providing the most appropriate treatment per clinical condition. According to CMS, the consultation must take place at the time of the order for the imaging service to meet the requirements for payment (2020).
According to CMS, this will affect multiple types of payments. “Claims from the professional and facility for advanced diagnostic imaging services furnished in these settings and paid by CMS using one of the following payment systems will be required to append AUC consultation information” (CMS, 2018): physician fee schedule, OPPS and ASC payments from CMS. This program will impact any facility that bills advanced diagnostic imaging services, whether it is “practitioners and facilities that furnish advanced diagnostic imaging services in a physician’s office, hospital outpatient department (including the emergency department), an ambulatory surgical center or an independent diagnostic testing facility (IDTF)” (CMS, 2020).
A list of qualified CDSM tools and more information on the AUC program is located on the CMS website.
The implementation of the CDSM will likely require a joint effort by many departments at each facility to fully prepare for the January 1, 2021 timeline and to prevent possible denials. Due to the enormity of this undertaking, YES highly recommends taking action on the implementation of this requirement as soon as possible.
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