Appropriate Use Criteria Program
NOTICE: The EDUCATIONAL AND OPERATIONS TESTING PERIOD for the AUC Program has been extended through CY 2021. There are no payment consequences associated with the AUC program during CY 2020 and CY 2021. We encourage stakeholders to use this period to learn, test and prepare for the AUC program.
The Protecting Access to Medicare Act (PAMA) of 2014, Section 218(b), established a new program to increase the rate of appropriate advanced diagnostic imaging services provided to Medicare beneficiaries. Examples of such advanced imaging services include:
- computed tomography (CT)
- positron emission tomography (PET)
- nuclear medicine, and
- magnetic resonance imaging (MRI)
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 appropriate use criteria (AUC) is accessed. The CDSM provides a determination of 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). A consultation must take place at the time of the order for imaging services that will be furnished in one of the below settings and paid for under one of the below payment systems. Ultimately, practitioners whose ordering patterns are considered outliers will be subject to prior authorization. Information on outlier methodology and prior authorization is not yet available.