Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging: Expect major Impact on Clinical Workflow, IT and Revenue Cycle

It is important to understand the requirements for Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging as well as the impact to expect on the various aspects of operations upon implementation.  

​Advanced diagnostic imaging is considered MRI, CT, PET, and Nuclear Medicine (X-rays, Ultrasound, and Fluoroscopy services are not included under the definition of advanced imaging). AUC links a specific clinical condition on presentation, services, and an assessment of the appropriateness of services. AUC’s evidence-based criteria for imaging is meant to assist clinicians in selecting the imaging study that is most likely to improve health care outcomes.

AUC for Advanced Diagnostic Imaging requires integration into a patient’s clinical workflow. Clinical decision support mechanisms (CDSMs) are electronic portals a clinician uses during a patient’s workup, and typically the CDSMs integrate with the EHR. Under this program, an order for an advanced diagnostic imaging service by a practitioner or clinical staff for a Medicare beneficiary, a consult of a qualified Clinical Decision Support Mechanism (CDSM), is a requirement. The CDSM determines whether the order adheres to AUC, or if the AUC consulted was not applicable (e.g., no AUC is available to address the patient’s clinical condition). This directly affects clinical workflows and processes and must be adjusted to adhere to requirements at the specific stage within the workflow.

The overarching goal for AUC is to ensure the effective use of technology to guide referring physicians to the appropriate imaging for a patient. It is recommended for providers to use a qualified CDSM (certified, meeting CMS requirements under the Social Security Act). If providers chose not to follow AUC requirements, CMS plans to institute prior authorization stipulations. For example, G codes are required for every advanced imaging service, and claims with multiple G-codes “shall be’’ accepted.

This program directly affects all physicians and practitioners that order advanced diagnostic imaging services and physicians, practitioners, and facilities that provide advanced diagnostic imaging services. This includes the hospital outpatient department, the emergency department, an ambulatory surgical center, or any independent diagnostic testing facility whose claims are paid under the physician fee schedule, hospital outpatient prospective payment system, or ambulatory surgical center payment system. In consideration of the complexity of the AUC program, CMS finalized an “educational and operations testing period” of one year that would begin on January 1, 2020.  With the volume of facilities, departments, people, and processes the AUC program effects, voluntarily adhering to the “educational and operations testing period” in the coming year is essential to prepare for the change adequately. 
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Providers are encouraged to take advantage of the CY 2020 and use this for testing on claim processing for the provider and CMS while there is still no impact on reimbursement. This is a significant change and has been in the works since 2016. CMS is not expected to delay the implementation any longer, as the AUC program is set to become mandatory on January 1, 2021, at which time claims will be denied if proper requirements are not met.

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​Further updates to the AUC program can be found in the CY 2019 PFS Final Rule (pages 59688-59701 and page 60074).

Questions regarding this program may be submitted to the CMS Imaging AUC resource box