09/16/2020
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program
CMS has extended the Educational and Operations Testing Period for the AUC Program thru 12/31/2021. The program is a part of the Protecting Access to Medicare Act (PAMA) of 2014. PAMA has met a great deal of push back from providers and their supporting organizations since it's inception. The testing period, which was set to end on 12/31/2020, allows providers who are delivering care to Medicare Part B members to test and gain an understanding of the process that they will be required to adhere to in order to obtain payment for certain, predefined diagnostic imaging services for these members. Once implemented providers will be requried to obtain a prior authorization via a fully qualified clinical decision support mechanism (CDSM) on all Medicare Part B members for the predefined testing under certain diagnoses. The intention of this portion of PAMA is to ensure that providers are ordering the most appropriate diagnostic imaging services for Medicare Part B members by requiring them to meet certain appropriate use criteria(AUC) when ordering highly utlized testing for a predefined group of diagnoses. These criteria are asked in question form via the CDSM and the provider answers the questions based on their patient's current symptoms and other clinical findings to determine if the diagnostic imaging the provider wishes to order is actually appropriate for evaluation of the patient's current condition. The expectation is that utilization of a CDSM and it's associated AUC will decrease inappropriate utilization of testing services for Medicare Part B members and point providers to more appropriate testing as well as promote the use of less costly and more effecitve measures for these members prior to moving to a more costly service.
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 Ac...
