Appropriate Use Criteria (AUC) Program
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The Centers for Medicare and Medicaid Services (CMS) has announced that the payment penalty phase will not begin 1/1/2023 and are unable to forecast when the payment penalty phase will begin. When the payment penalty phase does begin, all providers, or clinical staff under direct supervision of the ordering provider, will be required to consult Appropriate Use Criteria (AUC) with a qualified Clinical Decision Support Mechanism (qCDSM) at the time of ordering advanced diagnostic imaging services for Medicare beneficiaries.
The qCDSM is an electronic tool used by clinicians when ordering advanced diagnostic imaging services and assists you in making the most appropriate treatment decision for your patients to reduce radiation dose and improve quality of care.
The Protecting Access to Medicare Act (PAMA) of 2014, Section 218(b), establishes the Appropriate Use Criteria (AUC) Program, a nation-wide mandate with the goal to increase the rate of appropriate advanced diagnostic imaging services provided to Medicare beneficiaries.
CMS will deny any advanced diagnostic imaging claims that do not include AUC documentation, so if this information is missing on the order, Methodist staff will be reaching out to the ordering provider to obtain the AUC information before the service can be performed. Please ensure the AUC criteria is included in all advanced diagnostic imaging orders to avoid delays in patient care.
Advanced Diagnostic Services Include
Applicable Settings
After 2 years, CMS may begin reviewing physician claim data for compliance with the AUC Program and require non-compliant providers to obtain prior authorization before ordering advanced diagnostic imaging exams.
Additional information regarding the AUC program is available below:
Centers for Medicare & Medicaid Services
The AUC Program is codified in CMS regulations at 42 CFR 414.94 (PDF)
CMS MLN Matters Article: Claims Processing Requirements (CR11268, Transmittal 2323) (PDF)
CMS Manual System: Claims Processing Requirements (MM11268, Transmittal R2404OTN) (PDF)
AMA Reporting Appropriate Use Criteria in Claims for Medicare Patients
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Overview
The Centers for Medicare and Medicaid Services (CMS) has announced that the payment penalty phase will not begin 1/1/2023 and are unable to forecast when the payment penalty phase will begin. When the payment penalty phase does begin, all providers, or clinical staff under direct supervision of the ordering provider, will be required to consult Appropriate Use Criteria (AUC) with a qualified Clinical Decision Support Mechanism (qCDSM) at the time of ordering advanced diagnostic imaging services for Medicare beneficiaries.
The qCDSM is an electronic tool used by clinicians when ordering advanced diagnostic imaging services and assists you in making the most appropriate treatment decision for your patients to reduce radiation dose and improve quality of care.
The Protecting Access to Medicare Act (PAMA) of 2014, Section 218(b), establishes the Appropriate Use Criteria (AUC) Program, a nation-wide mandate with the goal to increase the rate of appropriate advanced diagnostic imaging services provided to Medicare beneficiaries.
CMS will deny any advanced diagnostic imaging claims that do not include AUC documentation, so if this information is missing on the order, Methodist staff will be reaching out to the ordering provider to obtain the AUC information before the service can be performed. Please ensure the AUC criteria is included in all advanced diagnostic imaging orders to avoid delays in patient care.
Advanced Diagnostic Services Include
- Computed Tomography (CT)
- Positron Emission Tomography (PET)
- Nuclear Medicine (NM), and
- Magnetic Resonance Imaging (MRI)
Applicable Settings
- Emergency Department
- Outpatient Clinics
- Ambulatory Surgical Center
- Independent Diagnostic Testing Facilities
How do I Consult Appropriate Use Criteria with a qCDSM
- Option 1: If you do not wish to use EPIC, or EpicCare Link, then you can Register for an account with a CMS approved vendor by accessing the CareSelect Imaging Open Access Portal.
- Click here for Tip Sheet: CareSelect Imaging Open Access Portal. Instructions on how to register & obtain AUC information begin on Page 2.
- Option 2: AUC are already built into EPIC and EpicCare Link, so if you order your advanced diagnostic imaging exams through either one, you will be compliant with the CMS requirement.
- To sign up for Epic Care Link
- Step 1: Navigate to this link: https://www.houstonmethodist.org/epiccarelink/
- Step 2: Under the Request Access section, click on the Request button to create an account.
- Step 3: Add Order Entry capability in EpicCare Link by filling out the appropriate Order Delegation Release Form and e-mail the completed form to helpdesk@houstonmethodist.org.
- Order Delegation Release Form – Single Provider Practice with one delegate.
- Order Delegation Release Form - Multi Provider Practice Staff is for larger practices with up to 9 providers and 9 delegates
- To sign up for Epic Care Link
Prior Authorization
After 2 years, CMS may begin reviewing physician claim data for compliance with the AUC Program and require non-compliant providers to obtain prior authorization before ordering advanced diagnostic imaging exams.
CPT Codes Impacted:
MRI
- 70336, 70540, 70542, 70543, 70544, 70545, 70546, 70547, 70548, 70549, 70551, 70552, 70553, 70554, 70555, 71550, 71551, 71552, 71555, 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72159, 72195, 72196, 72197, 72198, 73218, 73219, 73220, 73221, 73222, 73223, 73225, 73718, 73719, 73720, 73721, 73722, 73723, 73725, 74181, 74182, 74183, 74185, 75557, 75559, 75561, 75563, 75565, 76498, 77046, 77047, 77048, 77049
- C-codes: C8900, C8901, C8902, C8903, C8905, C8908, C8909, C8910, C8911, C8912, C8913, C8914, C8918, C8919, C8920, C8931, C8932, C8933, C8934, C8935, C8936
- 70450, 70460, 70470, 70480, 70481, 70482, 70486, 70487, 70488, 70490, 70491, 70492, 70496, 70498, 71250, 71260, 71270, 71275, 72125, 72126, 72127, 72128, 72129, 72130, 72131, 72132, 72133, 72191, 72192, 72193, 72194, 73200, 73201, 73202, 73206, 73700, 73701, 73702, 73706, 74150, 74160, 74170, 74174, 74175, 74176, 74177, 74178, 74261, 74262, 74712, 74713, 75571, 75572, 75573, 75574, 75635, 76380, 76497
- 76390
- 78012, 78013, 78014, 78015, 78016, 78018, 78020, 78070, 78071, 78072, 78075, 78099, 78102, 78103, 78104, 78110, 78111, 78120, 78121, 78122, 78130, 78135, 78140, 78185, 78191, 78195, 78199, 78201, 78202, 78215, 78216, 78226, 78227, 78230, 78231, 78232, 78258, 78261, 78262, 78264, 78265, 78266, 78267, 78268, 78278, 78282, 78290, 78291, 78299, 78300, 78305, 78306, 78315, 78350, 78351, 78399, 78414, 78428, 78429, 78430, 78431, 78432, 78433, 78434, 78445, 78451, 78452, 78453, 78454, 78456, 78457, 78458, 78459, 78466, 78468, 78469, 78472, 78473, 78481, 78483, 78491, 78492, 78494, 78496, 78499, 78579, 78580, 78582, 78597, 78598, 78599, 78600, 78601, 78605, 78606, 78608, 78609, 78610, 78630, 78635, 78645, 78650, 78660, 78699, 78700, 78701, 78707, 78708, 78709, 78725, 78730, 78740, 78761, 78799, 78800, 78801, 78802, 78803, 78804, 78811, 78812, 78813, 78814, 78815, 78816, 78830, 78831, 78832, 78835, 78999
Additional Information:
Additional information regarding the AUC program is available below:
Centers for Medicare & Medicaid Services
The AUC Program is codified in CMS regulations at 42 CFR 414.94 (PDF)
CMS MLN Matters Article: Claims Processing Requirements (CR11268, Transmittal 2323) (PDF)
CMS Manual System: Claims Processing Requirements (MM11268, Transmittal R2404OTN) (PDF)
AMA Reporting Appropriate Use Criteria in Claims for Medicare Patients