Healthcare Providers Must Be Prepared for the Appropriate Use Criteria Program

Keeping up to date with the ever-changing processes behind medical claims is a critical function of any thriving healthcare organization. With the latest program being handed down by the Center for Medicare and Medicaid (CMS), the Appropriate Use Criteria Program, it is crucial that providers begin preparing their organizations for the upcoming changes.??

The latest in required programs, AUC is designed to address the prescription of advanced diagnostic services for patients with Medicare coverage. With requirements being enforced by the close of 2021, this change will demand that internal health IT systems be programmed to support providers in complying with the new measures at the risk of widespread claims denial for advanced diagnostic services. So, what exactly is the program, and how do you prepare for its impact on your organization??

Program details?

The Appropriate Use Criteria Program was developed to increase the rate of appropriate advanced diagnostic imaging services provided to Medicare beneficiaries. Under the system, careful attention will be committed to each case submitted for evaluation. Patients whose conditions require specific diagnostic services to determine appropriate treatment will receive approval for payment through this system. Providers applying for advanced diagnostic services for patient cases where advanced diagnostics are not typically required will be notified to assign resources appropriately.?

Under the AUC program, any provider who orders an advanced diagnostic imaging service in an applicable setting for a service paid under an applicable payment system must consult a Clinical Decision Support Mechanism (CDSM) before proceeding. Many medical provider or medical center payment systems are considered applicable—for example, physician fee schedules, hospital outpatient payment systems, ambulatory surgery payment systems.?

A Clinical Decision Support Mechanism is an interactive digital tool that furnishes clinicians with current AUC guideline information. The information is used to make the most appropriate decisions regarding each patient's treatment, specific to each clinical condition. CDSM tools should be available or implemented in part with your EHR/EMR (electronic records software). It is critical that staff is well prepared and trained on how to utilize the CDSM appropriately.??

Clinical Decision Support Mechanisms must offer certain features, including the following…?

An applicable CDSM must contain AUC information from qualified Provider Led Entities (PLE)s with regards to joint and significant scenarios relevant to important clinical divisions, must be able to utilize more than one qualified PLE's information, maintain processes for updating, modifying, or removing AUC regularly, meet privacy, proper storage, and security standards - under applicable laws.?

A PLE is an interdisciplinary team of at least seven members that follows a publicly transparent, disclosed, and published process for determining each key point used for determining AUC via evidence or consensus-based information. The information is reviewed at least once per year, updated if necessary. PLEs are qualified for five years.?

Advanced diagnostic services to which AUC applies include:?

• Computed tomography?
• Positron emission tomography?
• Nuclear medicine?
• Magnetic resonance imaging?

Claims must include specific criteria in order to identify their adherence to the consulted AUC.?

For busy providers, these changes can mean a significant amount of investment in time and resources; however, it is worth noting that providers issuing orders may assign staff members working under their direction to perform AUC consultation in their place.?

How long will the grace period extend before compliance with AUC is required for claim reimbursement??

Currently, the AUC program deadline for full adoption is January 1, 2022. After that time, claims that have not passed through an AUC consultation with a qualified CDSM and are not accompanied by consulting information on the professional and the furnishing facility claim for the diagnostic imaging service will not be paid. This is important because CMS is utilizing the period before January 1, 2022 to serve as an Education and Operations Testing Period.??

During this testing period, providers are encouraged to begin implementing the process, and claims will not be denied for falling short of providing complete and proper AUC consultation details until the effective enforcement date.??

Now is the time to start implementing and testing your process and procedures for AUC compliance.?

How can providers be confident they are prescribing the most appropriate diagnostic tests for their patients while ensuring the treatment will be covered by Medicare??

Clinical Decision Support Mechanisms are invaluable for reaching a determination. Updating your health IT system will ensure your organization is prepared for CMSs enforcement of AUC by determining that an approved CDSM is integrated with your EHR software. If not, a standalone option can be utilized.?

Every provider affiliated with a medical facility who may order advanced diagnostic procedures - and every service - rendering provider who receives orders from the facility's providers must be aware of the new AUC program requirements and the essential nature of compliance.?

Procedural adjustments to workflows should be discussed with all providers involved as soon as possible to ensure everyone is up to speed before AUC goes into effect.?

Note: Administrators and providers at critical access hospitals (CAH)s must keep up to date on developments regarding alterations to AUC. Currently, these facilities are not required to report AUC information as they are not paid under an applicable payment system. It is not yet clear under the new criteria whether radiologists outside critical access hospitals who perform services ordered by CAH providers will be required to report AUC information. The possibility of a modification is expected.?

This is the time to familiarize and prepare for the Appropriate Use Criteria Program compliance enforcement. If you haven't started speaking with your technical and administration teams about these changes, now is the time to do so.?

Make sure your health IT system is adequately prepared to ensure ease of complying with the new requirements of AUC, to ensure all CMS claims will be paid. Should you need assistance in determining whether your system is suitably set up for ease of compliance when the Appropriate Use Criteria Program becomes mandatory in less than a year, feel free to reach out to me directly or to our team at [email protected]. We specialize in assisting medical providers with all types of compliance issues.?