What the new appropriate use criteria (AUC) means for your practice

Changes you can expect WITH AUC

The program requires Medicare Part B providers to use a Clinical Decision Support Mechanism (CDSM) to support their reasons for wanting to order advanced imaging services.

The CDSM is an interactive electronic tool often offered as part of an electronic health record (EHR). It shares AUC information and assists in determining appropriate treatment. Specifically, it “provides a determination of whether the order adheres to AUC, or if the AUC consulted was not applicable,” according to CMS.

Tests that now require consultation with the CDSM include:

• Computed tomography (CT)
• Magnetic resonance imaging (MRI)
• Positron emission tomography (PET)
• Nuclear medicine

After consulting the CDSM, providers ordering advanced imaging tests will need to give consultation information to the “furnishing professional,” or the provider conducting the imaging study.

An Education and Operations Testing Period began Jan. 1, 2020 to help providers gain experience meeting AUC without the risk of penalties. The test period will end Jan. 1, 2021, and providers will be required to comply with AUC to avoid claim denials thereafter.

“The purpose of the AUC program is to enable you to order the most appropriate test for your patient.”

Centers for Medicare & Medicaid Services

AUC background and benefits

Created as part of the Protecting Access to Medicare Act (PAMA) of 2014, AUC was designed to lower healthcare costs.

The data from the AUC program will allow CMS to pinpoint outliers among providers who order advanced imaging studies. As a result of their ordering behavior, these outliers will have to comply with prior authorization requirements when ordering these tests in the future.

According to research published in the Journal of the American Medical Association, high levels of healthcare spending are partially attributable to advanced imaging tests such as MRIs and CTs, which have a higher utilization rate and a higher cost per test in the United States.  

AUC aims to benefit providers and patients by verifying the necessity of expensive imaging studies.

Succeeding with AUC

Setting your practice up for success with AUC starts with understanding your resources. As you work to meet the new requirements, Greenway is here to make this process easier.

To implement AUC capabilities that support billing staff, we’ve created a workflow within the Intergy EHR to help providers comply with AUC.

Looking for additional informatioN on Appropriate use criteria?

CMS offers additional information about AUC and CDSMs on its AUC program page. Visit this page for background information and links to regulations and policies.