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Appropriate Use Criteria for Advanced Diagnostic Imaging – Testing Period Begins Soon!

Posted on August 26, 2019 in Health Law News

Published by: Hall Render

In late July 2019, CMS issued claims processing requirements for the educational and operations testing period for appropriate use criteria (“AUC”) related claims for advanced diagnostic imaging. Advanced imaging includes CT, PET, nuclear medicine, and MRI. The testing period begins January 1, 2020. The CMS Program Transmittal can be found here.


The Protecting Access to Medicare Act (“PAMA”) of 2014 established a program designed to increase the rate of appropriate advanced diagnostic imaging services furnished to Medicare beneficiaries. The program requires an ordering practitioner to consult a qualified Clinical Decision Support Mechanism (“CDSM”) electronic tool when ordering an advanced imaging service for a Medicare beneficiary. The CDSM communicates AUC information to the clinician user to assist them in making the most appropriate treatment decision for the patient. The CDSM will provide a determination of whether the practitioner’s order adheres to AUC, does not adhere to AUC, or if there is no applicable AUC. When the advanced imaging service is furnished in an applicable setting and paid under the physician fee schedule, hospital OPPS, or ASC payment system, AUC-related information will be required on the claim submitted to Medicare. Full implementation of the AUC program is expected January 1, 2021.

Claims Testing Period

Voluntary participation in the AUC program began July 1, 2018. Beginning January 1, 2020, CMS expects ordering practitioners to begin consulting qualified CDSMs and providing the AUC-related information to the providers/practitioners furnishing the advanced imaging for reporting on the claim. CMS claims processing systems will be prepared by January 1, 2020 to accept claims that contain the appropriate CPT or HCPCS code for advanced imaging with a line item modifier to describe the AUC information. Importantly, during the testing phase, claims will not be denied for failing to include the AUC-related information; but CMS states that “inclusion is encouraged.”

Practical Takeaways

  • Providers and suppliers of advanced imaging need to have procedures in place to request and require AUC-related information from ordering practitioners.
  • Ordering practitioners need to acquire and operationalize use of CDSMs in order to obtain the required AUC-related information.
  • Both furnishers of advanced imaging and ordering practitioners need to be aware of the situations where consulting a CDSM is required and when exceptions exist.
  • Both furnishers of advanced imaging and ordering practitioners should take advantage of the CY 2020 testing period to ensure the ability to submit appropriate claims for payment beginning in CY 2021.

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