Appropriate Use Criteria for Advanced Diagnostic Imaging Services - 2018 Final Rule

by  Jared Staheli, MPP
Dec 13th, 2017

What is the AUC program? From the CMS website:

Section 218(b) of the Protecting Access to Medicare Act of 2014 amended Title XVIII of the Social Security Act to add section 1834(q) directing CMS to establish a program to promote the use of appropriate use criteria (AUC) for advanced diagnostic imaging services. In section 1834(q)(1)(B) of the Act, AUC are defined as criteria that are evidence-based (to the extent feasible) and assist professionals who order and furnish applicable imaging services to make the most appropriate treatment decisions for a specific clinical condition.

The following table show which services are and are not affected by AUC. If your organization performs any of the Advanced Diagnostic Imaging Services listed below, the AUC applies to you.

Advanced Diagnostic Imaging Services	NOT Advanced Diagnostic Imaging Services
MRI Scan	X-ray
CT Scan	Fluoroscopy
PET Scan	Ultrasound

The goal of the AUC program is to have physicians consult AUC criteria through Clinical Decision Support Mechanisms (CDSMs) in order to receive payment from Medicare. The approved CDSMs can be found here.

The 2018 Final Rule has delayed the implementation date for the Medicare Appropriate Use Criteria (AUC) Program to January 1, 2020. In addition to this date of mandatory participation, voluntary participation will take place from July 2018 through December 2019 to prepare for implementation with real-world testing. For an unspecified period of time after January 1, 2020, the program will be in “an educational and operations testing period.” Claims will still be paid during this time regardless of the correctness of the information reported through the AUC program.

To address concerns regarding reporting burdens, the AUC program will count as a high-weighted improvement activity under MIPS. However, the AUC still exists as its own program, and is not simply a part of MIPS. If you are exempt from MIPS, or choose other improvement activities, AUC participation will still be mandated. The AUC program will count as an improvement category starting in 2018, even though participation is voluntary at this point, to encourage early-adoption of the program.

There are, however, some hardship exemptions, which include:

• Insufficient Internet Connectivity
• Practicing for less than 2 years
• Extreme and Uncontrollable Circumstances
• Lack of Control over the Availability of CEHRT
• Lack of Face-to-Face Patient Interaction

Another change in the final rule is a move away from the G-code and modifier combination, which attracted disapproval from many commenters. Instead, a “unique consultation identifier” will be reported on claims, with limited modifier usage for identifying exceptions to AUC consultation requirements. The standardized taxonomy for these identifiers will be developed during the voluntary phase of the program starting in 2018.

To read the Final Rule in its entirety, click here and see pages 53187-53201 and 53363.