New Medicare Mandate: Appropriate Use Criteria

Affects Orders for Advanced Imaging


Affects Orders for Advanced Imaging 

This year, you may begin hearing from the imaging departments or imaging facilities in your area about something called the "Appropriate Use Criteria" or clinical decision support mandate. Imaging centers may begin asking for or requiring that you provide them with additional information before they can move forward with an advanced image on your Medicare patients.

What is the Appropriate Use Criteria (AUC) Mandate?

The appropriate use criteria mandate is a Medicare program (which Congress created in 2014) designed to ensure that orders of advanced imaging are appropriate given the clinical condition of the patient. Any time a RHC clinician orders an advanced image (MRI, CT scan, nuclear medicine, or PET scan), the clinician must verify that this advanced image order is in fact necessary and proper.

The ordering professional is required to use a "qualified clinical decision support mechanism" (qCDSM) to query sets of "appropriate use criteria" in order to verify if the advanced image they want to order is clinically appropriate. In other words, your clinicians will need to verify at the time of the order, either through a qCDSM portal embedded in your EHR system, or through a free online portal that the advanced image is necessary for that Medicare patient.

While this may sound a lot like prior authorization, it is important to note that even if the AUC consultation indicates that the image is not appropriate, Medicare will still reimburse the imaging facility and radiologist for that image. After several years of data is collected by the Centers for Medicare and Medicaid Services (CMS), outlier ordering professionals (those with the highest rates of ordering imaging that is deemed not appropriate) will be subject to prior authorization.

When does the program start?

2020 is the beginning of a one-year "Educational and Operational Testing Period." During 2020, advanced imaging claims may include ~ but are not required to have ~ information regarding the AUC consultation. After the Educational and Operational Testing Period ends, advanced imaging claims must include AUC information in order to be paid. Unless CMS extends the educational period, imaging facilities will likely require that you provide them this information in 2021, or else they will not perform the requested advanced image (because they won’t get paid if they don’t put this information on their claim).

Does this policy apply to all advanced imaging?

No. This policy only applies to outpatient advanced imaging performed in an "applicable setting" and paid through an "applicable payment system." Critical Access Hospitals are not paid through an applicable payment system and are thus exempt from this program.

Are there any other exceptions?

Yes. Ordering professionals or clinicians will not have to consult AUC if: 1-the patient is deemed to be in an emergency medical condition; or 2-if the ordering professional has a hardship due to insufficient internet access, EHR or CDSM vendor issues, or extreme and uncontrollable circumstances (such as a natural disaster).

Does this apply to Medicare Advantage patients?

No. The AUC mandate is only applicable for traditional Medicare patients. 

New Medicare Mandate: Appropriate Use Criteria

What specific information will the imaging centers need from the ordering professional?

The imaging facility will need the following data elements provided by the ordering professional for their own imaging claims:

  1. the NPI of the ordering professional;
  2. the qCDSM used by the ordering professional (indicated by a G-code); and
  3. Whether the image ordered adhered, did not adhere, or was not applicable to the AUC (indicated through modifier codes).

Therefore, as ordering professionals, RHCs should consider adding this information (and fields for this information) to their physical and electronic imaging orders. Please see this MLN Matters document for specific information regarding which G-code corresponds with which qCDSM, as well as a breakdown of which modifier code indicates which result.

To be clear, all ordering professionals must use one of the qCDSM tools listed on this webpage. These tools allow clinicians to access various sets of "appropriate use criteria" that are maintained by provider led entities with expertise on imaging. These appropriate use criteria sets will provide clinicians with guidance surrounding clinical best practices and standards for advanced imaging.

Can ordering professional delegate the AUC consultation?

Yes, but the delegation must be to other clinical staff under the direction of the ordering professional with "sufficient clinical knowledge to interact with the qCDSM and communicate with the ordering professional."

Where can one get more information?

The facilities and imaging departments that perform these advanced images for patients in your area will likely provide you guidance on this new mandate if you ask them. However, here are additional resources for your convenience:

Full disclosure: In addition to my work with the National Association of Rural Health Clinics, I also work with AHRA:The Association for Medical Imaging Management on this subject. As such, I am happy to answer any questions folks in rural health community may have about this forthcoming mandate. Please feel free to email or call me if questions come up.

Nathan Baugh
Director of Government Affairs
National Association of Rural Health Clinics
(202) 543-0348