The Protecting Access to Medicare Act (PAMA) of 2014 established a program to promote the use of Appropriate Use Criteria (AUC) for advanced diagnostic imaging services. Specifically, ordering professionals will be required to consult with AUC prior to ordering an advanced diagnostic imaging service (CT, MR, SPECT, or PET). The furnishing professional will not be paidby Medicare unless they document that the ordering professional consulted with AUC. The initial priority clinical areas for the AUC program include coronary artery disease (suspected or diagnosed) and suspected pulmonary embolism. As of this writing, it is expected this program will take effect January 1, 2018; however, multiple stakeholders have called on CMS to delay implementation of this program. Additional details are expected to become available in early July, 2017.
CMS has chosen to promulgate regulations to implement this program through a multi-year process. Over the past two years, CMS has focused on determining that AUC must be developed or endorsed by qualified provider-led entities as designated by CMS. The initial list of qualified entities is posted on the CMS website at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/index.htmland includes the American College of Cardiology (ACC) and the American College of Radiology (ACR). AUC content will be licensed and delivered by vendors in the form of electronic clinical decision support mechanisms. The clinician will consult the AUC using these support mechanisms to determine and document the level of clinical appropriateness for an advanced diagnostic imaging service for a given patient’s clinical scenario.
Under this AUC program, CMS will collect data on provider ordering practices. Those found to be outliers will be subject to prior authorization for advanced diagnostic imaging services effective January 2020.
Early this summer, CMS is expected to propose additional regulations to govern implementation of this program. SCMR will review the regulations and comment by the close of the comment period. We will update SCMR members when additional final regulations are released later this year.