The Protecting Access to Medicare Act (PAMA) requires the Centers for Medicare & Medicaid Services (CMS) to establish a program that promotes Appropriate Use Criteria (AUC) for advanced diagnostic imaging. AUC are evidence-based criteria that assist professionals who order and furnish certain imaging services to make the most appropriate treatment decisions for a specific clinical condition.

When the AUC program is implemented, the law requires that payment be made to the furnishing professional for an applicable advanced diagnostic imaging service only if the claim indicates that the ordering professional consulted with a qualified clinical decision support mechanism (CDSM) as to whether the ordered service adheres to applicable AUC.

An “ordering professional” is a physician or practitioner who orders an applicable imaging service. In the Calendar Year 2019 Physician Fee Schedule Final Rule, CMS clarified that “furnishing professional” includes the furnishing facility that provides the advanced diagnostic imaging service.

Here are key parameters to be aware of:

Advanced diagnostic imaging services: MRIs, CT scans, SPECT scans, and nuclear medicine

Applicable settings: Hospital outpatient departments, emergency departments, ambulatory surgery centers, physician offices, and independent diagnostic testing facilities

Applicable payment systems: Physician fee schedule, outpatient prospective payment system, ambulatory surgical center payment systems

Reporting to CMS: Furnishing professionals and facilities must report CDSM consultation information on claims.

Information required on claims: Include the applicable G-codes, modifiers, and ordering physician’s NPI.

Timeline of Next Steps
Since January 1, 2018, eligible clinicians have been able to earn MIPS credit in the Improvement Activities category for meeting AUC requirements. Next steps include:

Now through December 31, 2019: Voluntary reporting of limited consultation information

2020: Educational and operations testing year (CMS will pay claims whether or not they correctly include AUC information)

2021 and beyond: Development of outlier criteria and full implementation of the AUC program

– James J. Matera DO, FACOI