In 2014, the U.S. Congress enacted the Protecting Access to Medicare Act (PAMA) that, in part, directed the Centers for Medicare and Medicaid Services (CMS) to establish a program to promote the use of appropriate use criteria (AUC) for advanced diagnostic imaging services. Since the enactment of PAMA, CMS has taken multiple steps toward full implementation of this program. (The regulation describing the AUC program requirements is codified at 42 CFR 414.94.)

The program is designed to promote appropriate outpatient utilization of AUC for advanced diagnostic imaging services (CT, MRI, and nuclear medicine/PET) when ordered for Medicare outpatients. CMS has approved AUC that has been developed by provider-led entities selected by CMS, such as national professional medical specialty societies like the American College of Radiology. Ordering physicians or other practitioners are required to consult AUC, and the furnishing imaging facility and interpreting radiologist must report information about that consultation when submitting claims for reimbursement.

The AUC program has yet to be fully implemented in part due to its complicated and challenging compliance requirements; thus the program remains controversial. CMS continues to get pushback from critics of the program. In the CY 2022 Medicare Physician Fee Schedule proposed rule, CMS announced its intention to hold off on the processing systems for AUC claims edits – and on the payment penalty phase of the program – until the latter of January 1, 2023, or the January 1 of the year after the year in which the public health emergency (PHE) for COVID-19 ends.

The American College of Radiology supports the CMS proposed timeline for AUC implementation. But others want to see the program curtailed or substantially changed. 

In a Health Affairs blog article published on August 25, 2021, a team of radiologists, other physician specialists, and healthcare administrators with health policy expertise from Johns Hopkins, Harvard, and Weill Cornell have made a strong case for substantial revisions to the AUC program. While acknowledging their recommendations likely require Congressional action, they argue that despite the laudable goals of PAMA, the complex and technically difficult claims process required to comply with PAMA's AUC mandate "will inevitably result in the denial of reimbursement for many claims for advanced imaging, most of which will likely be necessary and appropriate for Medicare beneficiaries."

I urge you to read their blog post. Whether one agrees or disagrees with their recommendations, one must commend the authors on their carefully considered and well-reasoned proposals for modifying the AUC program before it becomes fully implemented. These policy analysts hope that CMS will consider the impact of the PAMA AUC program on access to imaging for Medicare beneficiaries – and the anticipated significant administrative burdens associated with the program – before making it final. 

It will be fascinating to see whether the critique offered by these authors or the likely pushback from others will delay or derail the ultimate implementation of the AUC program.