The Centers for Medicare and Medicaid Services (CMS) has provided an update regarding the Appropriate Use Criteria (AUC) Program established by The Protecting Access to Medicare Act (PAMA) of 2014. Under this program, at the time a practitioner orders an advanced diagnostic imaging service for a Medicare beneficiary, he/she, or clinical staff acting under his/her direction, will be required to consult a qualified Clinical Decision Support Mechanism (CDSM). CDSMs are electronic portals through which AUC is accessed.
Ultimately, practitioners whose ordering patterns are considered outliers will be subject to prior authorization. The AUC Program began its one-year educational and operations testing phase on Jan. 1, 2020, and was supposed to be completely implemented by Jan. 1, 2021. At that point, claims that fail to append this information would not be paid.
There was significant concern that referring physicians and sites would not be ready for the implementation phase due to the COVID-19 public health emergency. Therefore, CMS’ announcing a one-year delay in the implementation phase (until Jan. 1, 2022) provides relief to the referring physicians and gives additional time to prepare for the implementation of this program.