Protecting Access to Medicare Act (PAMA) Appropriate Use Criteria (AUC) for Advanced Imaging Services

Section 218(b) of the Protecting Access to Medicare Act of 2014 added section 1834(q) directing CMS to establish a program to support the use of an appropriate use criteria (AUC) before ordering advanced diagnostic imaging services for Medicare patients. In this section of the Act, AUC are defined as criteria that are evidence-based (to the extent feasible) and assist professionals who order and provide applicable imaging services to make the most appropriate treatment decisions for a specific clinical condition.

The program will require the practitioner ordering the advanced diagnostic imaging service to consult an AUC using a clinical decision support mechanism for all Medicare patients. The health care professional who provides the advanced imaging service will be required to report that the ordering practitioner consulted an AUC in order to be paid for the service provided.

This program was to go into effect on January 1, 2017. The Centers for Medicare and Medicaid Services (CMS) has made a decision to postpone the start date as there is still much to be resolved. CMS is anticipating the new start date to be January 1, 2018. One of the most pressing issues to be resolved is how the provider of the imaging service will report the ordering physician’s use of an AUC. CMS has considered modifying claim forms or use of modifiers but nothing has been decided or finalized.

We are expecting additional information to be published by CMS this summer and in the 2018 PFS rulemaking process.  Meridian Medical Management will continue to monitor changes and updates to this program as they become available and will keep our clients informed of any changes.

For more information regarding Appropriate Use Criteria please go to:

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/index.html