Published 12/31/2019
Wilford K. Gibson, MD, FAAOS; Julie Williams

CMS: Appropriate Use Criteria Encouraged with Advanced Diagnostic Imaging

Editor’s note: The article’s content was current at press time. 

On Jan. 1, the Centers for Medicare & Medicaid Services (CMS) implemented an “educational and operations testing period” for required consultation with appropriate use criteria (AUC) when advanced diagnostic imaging is ordered. Claims that do not include the AUC-related information will not be denied, but the agency is encouraging ordering professionals to begin consulting AUC through a qualified clinical decision support mechanism (CDSM) this year. CMS also is providing information to furnishing practitioners and professionals for reporting their claims. In addition to the tool for ordering physicians, CMS is providing tools for practitioners performing the studies as well.

Considering the added administrative burden and anticipated cost of compliance, the AUC program appears to be a disproportionate response to the targeted problem of clinically inappropriate utilization of imaging. Professionals already are struggling to make the investments necessary for successful participation in the Merit-based Incentive Payment System (MIPS) or alternative payment models (APMs); those challenges include having to purchase and utilize expensive electronic health record (EHR) systems and hiring support staff to ensure adequate compliance.

Duplicative of other quality programs

The CMS action comes amid growing skepticism throughout the professional community that CMS can overcome the operational challenges that appear to be plaguing implementation of the Medicare AUC program. Created by Congress in 2014 via the Protecting Access to Medicare Act (PAMA), the program is now outdated—especially as Medicare continues its pivot toward value-based models that put professionals at risk for failing to control costs and increase, or at least maintain, quality of care.

An example of the excessive burden and duplication of efforts being placed on physicians is the Bundled Payment for Care Improvement–Advanced model. Clinicians are spending thousands of dollars on risk-stratification efforts, care redesign, and increased costs for staff and compliant EHRs for registry reporting. Through those programs, they also are providing evidence-based care. An additional mandatory requirement such as the AUC program is not only duplicative but also meaningless in the context of musculoskeletal care.

The scale and complexity of the Medicare AUC program are significant. The program touches virtually every clinician who orders or furnishes an advanced diagnostic imaging test. Complexity arises when ordering clinicians are restricted by the manner in which they must consult AUC, when they must transfer information to clinicians or healthcare professionals who are furnishing the tests, and then when furnishing professionals have to provide documentation of specific information on Medicare claim forms.

Because a standard and technological solution for transferring information is still in development, professionals may need to rely on manual workflows to exchange required information. In addition to technical challenges, the proprietary, qualified CDSMs that clinicians must use may restrict the AUC they can consult. Physicians may be unable to consult the AUC best suited for their practice, such as those developed within a specialty.

Efforts to delay implementation and change the law

Physicians led the way with the development of AUC for diagnostic imaging and continue to advocate for their use. Furthermore, under Medicare’s Quality Payment Program (QPP), physicians and other professionals who participate in risk-based APMs and are held accountable for costs in MIPS already are being incentivized to consult AUC. This structure benefits patients by reducing serial testing and unnecessary invasive procedures, as well as minimizing radiation exposure. Thus, consultation of AUC should be encouraged but must be balanced against the administrative and regulatory burden.

AAOS has taken a two-pronged approach in opposing these changes. Because AUC reporting is congressionally mandated, any changes to PAMA or the Medicare Access and CHIP Reauthorization Act (MACRA) require legislative action. AAOS and a coalition of other medical specialties have engaged with the House Ways and Means Committee and the Senate Finance Committee on a proposal that would deem healthcare professionals compliant with the AUC program if they meet the requirements of the QPP, rather than perpetuating PAMA and MACRA.

In terms of regulatory implementation, AAOS has consistently urged that the AUC program remain voluntary. In May 2019, AAOS joined 22 medical organizations in asking CMS that participation in the AUC program remain voluntary through at least this year. That letter was followed by a meeting with high-level staff at the agency. AAOS argued that it could not be implemented without significant disruption to physicians, hospitals, and other healthcare professionals.

In June 2019, AAOS joined other physician societies on Capitol Hill in asking lawmakers to take a different approach to encouraging AUC consultation in place of the overly prescriptive and complex AUC program outlined in PAMA.

Support for high-value performance

AAOS will continue to work with a coalition of medical specialties on this effort to modify the law. Clinicians must be afforded maximum flexibility in the use of AUC, in the least administratively burdensome manner possible, while meeting the intent of PAMA to ensure appropriate imaging through enhanced education of ordering professionals and support for clinicians in achieving high-value performance through QPP.

Learn more by reading the coalition letter to the House Ways and Means Committee at https://www.bit.ly/2E7E0xQ and the Centers for Medicare & Medicaid Services fact sheet on appropriate use criteria for advanced diagnostic imaging at https://go.cms.gov/2FQfTEC.

Wilford K. Gibson, MD, FAAOS, is chair of the AAOS Council on Advocacy.

Julie Williams is a senior manager in the AAOS Office of Government Relations.

Claims will not be denied for failing to include AUC-related information

Physicians who order and refer patients for imaging tests during the Educational and Operations Testing Period may by contacted by radiology labs with the message that, effective Jan. 1, the Protecting Access to Medicare Act “requires” referring providers to consult appropriate use criteria (AUC) prior to ordering advanced diagnostic imaging services.

The Centers for Medicare & Medicaid Services, however, has issued a Medicare Learning Network notice, which states that this year it “expects” ordering professionals to begin consult- ing qualified clinical decision support mechanisms and providing information to the furnishing practitioners and professionals for reporting on their claims.

Importantly, claims will not be denied for failing to include AUC-related information or for misreporting AUC information on nonimaging claims. Examples include failure to note modifiers and/or G codes or reporting modifiers on the wrong line or wrong service.