Beginning Jan. 1, 2021, the Centers for Medicare & Medicaid Services will require physicians and practices that order advanced diagnostic imaging services for Medicare patients to check whether these orders adhere to new standards called appropriate use criteria (AUC).

The AUC program was established in 2014 by the Protecting Access to Medicare Act (PAMA), to increase the rate of appropriate advanced diagnostic imaging services provided to Medicare beneficiaries. 

Examples of such advanced imaging services include:

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

Under this program, at the time a practitioner orders an advanced diagnostic imaging service for a Medicare beneficiary, the physician or clinical staff acting under the physician’s direction will be required to consult a qualified Clinical Decision Support Mechanism (CDSM). 

CDSMs are electronic portals through which clinicians and facilities can access appropriate use criteria (AUC). The CDSM will determine whether the order adheres to AUC, or if the AUC consulted was not applicable, for example, when no AUC is available to address the patient’s clinical condition. 

This program affects all physicians and practitioners who order advanced diagnostic imaging services, as well as physicians, practitioners and facilities that furnish advanced diagnostic imaging services in:

• Physician offices;
• Hospital outpatient departments (including emergency departments);
• Ambulatory surgical centers (ASCs); or
• Independent diagnostic testing facilities; and

where claims are paid under one of these payment systems:  

• Physician Fee Schedule;
• Hospital Outpatient Prospective Payment System; or
• Ambulatory surgical center payment system.

Program timeline

The AUC program is now operating on a voluntary basis. Since Jan. 1, 2020, the program has also been operating in an Education and Operations Testing Period, during which claims will not be denied for failing to include proper AUC consultation information.

The program is set to be fully implemented on Jan. 1, 2021. As of that date, physicians, other clinicians and practices that meet the criteria for the AUC program will be required to consult qualified CDSMs and to report the AUC consultation information on claims submitted by the professional and the facility that furnished the advanced diagnostic imaging service. Claims will not be paid if they do not include this information. 

ISMA members with questions about the AUC program and how to implement the new requirements may contact ISMA at 317-261-2060 or 800-257-4762.

Other resources

CMS AUC >>

Your Medicare administrative contractor (MAC) >>

Email CMS >>