From the April 2017 issue of HealthCare Business News magazine
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
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• 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.Back to HCB News
