Mutual Matters

Medicare Update - Appropriate Use Criteria 

Posted by Hoyt Torras, MPA, MHA on Jan 19, 2018 12:05:00 PM

This summary is based primarily on the Medicare Physician Fee Schedule CY2018, Final Rule – Published in the Federal Register November 15, 2017.

MMIC_clipboard_patient discussion.jpgIn 2014, Congress enacted legislation designed to promote use of Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging Services. Implementing this program has proven a more difficult endeavor than was originally anticipated. For this reason, there have been several delays in the program and there are still items that CMS has not finalized. 

Stripped to its basics, Appropriate Use Criteria (AUC) is a more advanced form of “clinical guidelines.” AUC help clinicians determine what imaging should be performed based upon the individual patient, scientific evidence, risk/benefit of testing, available healthcare resources, etc. Appropriateness criteria is believed to improve outcomes and resource utilization. In some respects, use of appropriateness criteria is simply transferring prior approval (pre-certification) to medical practices. Clearly, the program is designed to address potential inappropriate use of imaging.

To facilitate utilization of appropriateness criteria, CMS is mandating that certain organizations help develop the appropriateness criteria. Further, CMS is certifying electronic Clinical Decision-Support Mechanisms (CDSMs); essentially, systems that ordering physicians can employ to check criteria for appropriate use.

Physicians and other professionals ordering and/or furnishing advanced imaging would be required to report to Medicare whether AUC were consulted before the imaging was ordered. Although it is not settled yet, the reporting mechanism appears to be headed toward use of modifiers or special G-codes that would be submitted on claim forms to indicate the use of appropriateness criteria. There might also be unique identifiers produced by the CDSMs that could be submitted to indicate AUCs were employed prior to ordering the tests.

Discover the impact of this program and more about this medicare update by clicking below. 

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