CMS implements AUC requirements for advanced imaging services
April 12, 2017
On Nov. 15, 2016, the Centers for Medicare & Medicaid Services (CMS) released the Calendar Year 2017 Medicare Physician Fee Schedule (MPFS) final rule. In this final rule, CMS continued the process of implementing the policy requirement whereby providers would have to consult applicable Appropriate Use Criteria (AUC) prior to ordering advanced diagnostic imaging services, including MRI, CT, PET and nuclear cardiology. CMS also finalized the priority clinical areas that will be used to measure so-called “outlier professionals” in this CY 2017 final rule. These outlier professionals would then be subjected to prior authorization requirements for at least two years if they were in the top 5 percent of physicians whose ordering of advanced imaging did not meet the AUC guidelines.
In the CY 2017 final rule, CMS also stated that it is planning to finalize all remaining elements of this program during the CY 2018 Medicare Physician Fee Schedule rulemaking process. The proposed rule for CY 2018 should be released for comment in early July 2017. CMS anticipates that this will allow the AUC consultation requirement to be in place starting Jan. 1, 2018. In implementing this new policy requirement, CMS selected a list of provider-led entities that applied to CMS stating they could provide one or more AUCs for use by physicians to comply with the law’s AUC consultation requirements starting Jan. 1, 2018. The following are the organizations that were selected as of June 1, 2016:
• American College of Cardiology Foundation
• American College of Radiology
• Brigham and Women’s Physicians Organization
• CDI Quality Institute
• Intermountain Healthcare
• Massachusetts General Hospital, Department of Radiology
• National Comprehensive Cancer Network
• Society for Nuclear Medicine and Molecular Imaging
• University of California Medical Campuses
• University of Washington Physicians
• Weill Cornell Medicine Physicians Organization
CMS must also identify and publish a list of qualified clinical decision support (CDS) mechanisms (electronic software) that could be used by ordering professionals to consult with the applicable AUC. Many CDS mechanisms can be seamlessly embedded within an electronic health record. CMS will announce the CDS mechanisms that have been selected by July 1, 2017. This will give providers in offices, hospital outpatient departments and ambulatory surgical centers time to obtain a system and become familiar prior to Jan. 1, 2018.
CMS finalized an initial list of priority clinical areas, defined as clinical conditions, diseases or symptom complexes, and associated advanced diagnostic imaging services on Nov. 15, 2016. The diagnosis codes that were used to describe the proposed priority clinical areas can be found on the CMS AUC program web page. The list of clinical priority areas includes:
• Coronary artery disease (suspected or diagnosed)
• Suspected pulmonary embolism
• Headache (traumatic and non-traumatic)
• Hip pain
• Low back pain
• Shoulder pain (to include suspected rotator cuff injury)
• Cancer of the lung (primary or metastatic, suspected or diagnosed)
• Cervical or neck pain
Once the AUC program requirements start on Jan. 1, 2018, Medicare will no longer pay claims for technical component or professional component reimbursement to rendering providers for advanced imaging services in the Medicare Physician Fee Schedule, Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Prospective Payment System, unless the ordering physician has consulted with an AUC before making the order.
Ordering professionals that CMS has identified as “outliers” with low rates of AUC adherence relative to their peers on the priority clinical areas identified above based on the previous two years of data will be required to obtain prior authorization from CMS before advanced imaging orders can be furnished starting Jan. 1, 2020. No more than 5 percent of the ordering physician population can be deemed an outlier.
To learn more about the CMS implementation of the AUC program, please visit the CMS web page on the Appropriate Use Criteria Program. Or read the section in the CY 2017 Final Rule for the Medicare Physician Fee Schedule at Federal Register / Vol. 81, No. 220 / Tuesday, Nov. 15, 2016 / Rules and Regulations, pages 80403 — 80428.
About the author: Jill Rathbun is managing partner at Galileo Consulting Group.
In the CY 2017 final rule, CMS also stated that it is planning to finalize all remaining elements of this program during the CY 2018 Medicare Physician Fee Schedule rulemaking process. The proposed rule for CY 2018 should be released for comment in early July 2017. CMS anticipates that this will allow the AUC consultation requirement to be in place starting Jan. 1, 2018. In implementing this new policy requirement, CMS selected a list of provider-led entities that applied to CMS stating they could provide one or more AUCs for use by physicians to comply with the law’s AUC consultation requirements starting Jan. 1, 2018. The following are the organizations that were selected as of June 1, 2016:
• American College of Cardiology Foundation
• American College of Radiology
• Brigham and Women’s Physicians Organization
• CDI Quality Institute
• Intermountain Healthcare
• Massachusetts General Hospital, Department of Radiology
• National Comprehensive Cancer Network
• Society for Nuclear Medicine and Molecular Imaging
• University of California Medical Campuses
• University of Washington Physicians
• Weill Cornell Medicine Physicians Organization
CMS must also identify and publish a list of qualified clinical decision support (CDS) mechanisms (electronic software) that could be used by ordering professionals to consult with the applicable AUC. Many CDS mechanisms can be seamlessly embedded within an electronic health record. CMS will announce the CDS mechanisms that have been selected by July 1, 2017. This will give providers in offices, hospital outpatient departments and ambulatory surgical centers time to obtain a system and become familiar prior to Jan. 1, 2018.
CMS finalized an initial list of priority clinical areas, defined as clinical conditions, diseases or symptom complexes, and associated advanced diagnostic imaging services on Nov. 15, 2016. The diagnosis codes that were used to describe the proposed priority clinical areas can be found on the CMS AUC program web page. The list of clinical priority areas includes:
• Coronary artery disease (suspected or diagnosed)
• Suspected pulmonary embolism
• Headache (traumatic and non-traumatic)
• Hip pain
• Low back pain
• Shoulder pain (to include suspected rotator cuff injury)
• Cancer of the lung (primary or metastatic, suspected or diagnosed)
• Cervical or neck pain
Once the AUC program requirements start on Jan. 1, 2018, Medicare will no longer pay claims for technical component or professional component reimbursement to rendering providers for advanced imaging services in the Medicare Physician Fee Schedule, Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Prospective Payment System, unless the ordering physician has consulted with an AUC before making the order.
Ordering professionals that CMS has identified as “outliers” with low rates of AUC adherence relative to their peers on the priority clinical areas identified above based on the previous two years of data will be required to obtain prior authorization from CMS before advanced imaging orders can be furnished starting Jan. 1, 2020. No more than 5 percent of the ordering physician population can be deemed an outlier.
To learn more about the CMS implementation of the AUC program, please visit the CMS web page on the Appropriate Use Criteria Program. Or read the section in the CY 2017 Final Rule for the Medicare Physician Fee Schedule at Federal Register / Vol. 81, No. 220 / Tuesday, Nov. 15, 2016 / Rules and Regulations, pages 80403 — 80428.
About the author: Jill Rathbun is managing partner at Galileo Consulting Group.