Preparation for appropriate use criteria is key to success

If providers fail to follow these new rules, claims will be denied, and eventually, those who are outliers on adherence to appropriate use criteria will be subject to prior authorization.

Mandatory participation in the Centers for Medicare and Medicaid Services (CMS) Appropriate Use Criteria (AUC) program is right around the corner. Beginning January 1, 2022, providers who order an advanced diagnostic imaging service for a Medicare beneficiary will be required to consult a Clinical Decision Support Mechanism (CDSM) to gauge adherence to evidence-based criteria and report the consultation information to CMS via claims to avoid denial of payment. Certified by CMS as approved vendors, CDSMs tell the provider whether a study adheres to Medicare criteria. If providers fail to follow these new rules, claims will be denied, and eventually, those who are outliers on adherence to appropriate use criteria will be subject to prior authorization.

Originally scheduled to start in 2021, the program was delayed due to COVID-19. Hopefully, those affected by the new rules are using the extra time wisely, preparing for the requirements. For those just beginning the process, a quick overview of how to efficiently implement the program is worthwhile.

Which providers and services are affected?

By now, providers impacted by AUC should be well aware they will be affected by the program. Those most affected are providers on the patient side who order an imaging study and the furnishing providers who actually do the imaging and interpret the results.

The most common advanced imaging services that require CDSM consultations include computed tomography (CT), positron emission tomography (PET), nuclear medicine, and magnetic resonance imaging (MRI). Medicare has identified certain high-priority areas for CDSMs to focus on for under or over utilization of diagnostics. They include the following:

  • Coronary artery disease
  • Suspected pulmonary embolism
  • Headache
  • Hip pain
  • Low back pain
  • Shoulder pain
  • Cancer of the lung (primary or metastatic, suspected or diagnosed)
  • Cervical or neck pain

CDSM selection

Each practice must determine which CDSM to utilize. There are some free options, as the government wants to ensure practices with financial concerns will still to be able to meet program requirements. These free CDSMs are stand-alone and therefore are not integrated into the practice electronic health record (EHR) workflow and often only have content on high-priority areas above, a major drawback.

The best approach for selecting a CDSM is for practices to reach out as early as possible to their EHR vendors to see which CDSM they are partnering with, as that will provide an integrated solution. Practices should request a demo and start educating themselves as soon as possible. By adopting these new procedures now, the required workflow can be established to ensure they are ready for next year. If their EHR vendor is not recommending or partnering with a CDSM, practices should go to CMS’ list of certified CDSM vendors to investigate which one can best meet their needs.

Best practices

In addition to reaching out to their EHR vendors, there are some other actions practices should take to ensure they can successfully meet AUC requirements:

  • Start as early as possible, so everyone has time to adjust. Identify the solutions that will be available and start educating your care teams and support staff.
  • Ordering providers should contact their primary furnishing providers, whether they utilize in-house imaging or an external center, to see how they are preparing and what processes they expect ordering providers to follow. The process should be worked out as early as possible.
  • Determine who will own the AUC process within the practice. Should the care team at the point of care be responsible, or would it be better handled by someone more in the background, such as a clinical reviewer?
  • Examine workflow within the revenue cycle, especially if the practice is doing in-house imaging. Make sure orders are finalized and that G-codes and modifiers are on the claim from the AUC event. These identify the CDSM and whether the study adhered to the criteria, not applicable, amongst other outcomes.
  • Establish an AUC lead to make sure all the dots are connecting to prepare and be successful. This could be an imaging specialist or a clinical quality leader.
  • Once processes are established, make sure everyone is adopting. When choosing a CDSM solution, select those with reporting capabilities so providers can be tracked to ensure they are doing an AUC check within their ordering process. 
  • Monitor providers’ adherence levels to see if they are improving over time so they will be above the eventual threshold that determines whether prior authorization will be required.
  • As part of the overall adoption process, stress education and communication so everyone is aware of their roles.

Good intentions but burdensome 

Overall, the goal of the AUC program is good, as it seeks to ensure patients have access to the appropriate, evidence-based studies they need while preventing overutilization. It also aligns with the tenants of value-based care by attempting to make sure providers are doing the right studies for the right condition at the right time.

Unfortunately, however, it assigns more tasks to already overburdened care teams and support staff. Those who have offered early feedback say so much is required before a study can occur, it almost feels like they are actually operating under prior authorization. Therefore, it is highly recommended to develop well thought-out and clear plans sooner rather than later to ease the burden.