Appropriate Use Criteria Program Finalized

The Protecting Access to Medicare Act (PAMA) of 2014, Section 218(b), established a new program to increase the rate of appropriate advanced diagnostic imaging services provided to Medicare beneficiaries. Ordering providers must consider options for advanced radiology services by consulting qualified software-based Clinical Decision Support Mechanisms (CDSMs).

Currently, the Appropriate Use Criteria (AUC) program is set to be fully implemented on January 1, 2021, which means that AUC consultations with qualified CDSMs must take place along with reporting of consultation information on the furnishing professional and furnishing facility claim for the advanced diagnostic imaging service. Claims that fail to append this information will not be paid. Prior to 1/1/21, the program will operate in an Education and Operations Testing Period starting January 1, 2020, during which claims will not be denied for failing to include proper AUC consultation information.

The program will be used to apply criteria to eight priority clinical areas:
• Coronary artery disease (either suspected or diagnosed)
• Suspected pulmonary embolism
• Headache (traumatic and non-traumatic)
• Hip pain
• Low back pain
• Shoulder pain (including suspected rotator cuff injuries)
• Cancer of the lung (primary or metastatic, suspected or diagnosed)
• Cervical or neck pain

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