Once again, we can hear a drumbeat of calls to repeal the Medicare program requiring the consultation of appropriate use criteria (AUC) when outpatient advanced diagnostic imaging services are ordered. A coalition of more than 30 medical societies is urging Congress to repeal the AUC program for advanced diagnostic imaging. Efforts to repeal the AUC program are not universal, though, as the American College of Radiology (ACR) and others - such as major health systems - maintain support for the program.

The AUC program has yet to be fully implemented - in part due to its complicated and challenging compliance requirements - and as we approach the implementation of the program, it remains controversial. The Centers for Medicare & Medicaid Services (CMS) continue to get push back from critics of the program. But in the CY 2022 Medicare Physician Fee Schedule Rule, CMS announced its intention to begin processing systems for AUC claims edits – and turn on the payment penalty phase of the program – on January 1, 2023, or January 1 of the year after the public health emergency for COVID-19 ends.

In 2014, the U.S. Congress enacted the Protecting Access to Medicare Act (PAMA) that, in part, directed CMS to establish a program to promote appropriate use of advanced diagnostic imaging services. 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 various sets of appropriate use criteria that have been developed by provider-led entities selected by CMS, such as national professional medical specialty societies like the American College of Radiology. When implemented, ordering physicians or other practitioners will be required to consult AUC via a clinical decision support mechanism, and the furnishing imaging facility and interpreting radiologist must report information about that consultation when submitting claims for reimbursement.

The genesis of ACR's support for AUC was grounded in the need to find an alternative to CMS requiring pre-authorization for all advanced imaging. The ACR believes that AUC consultation allows physicians to choose the best test for patients based on those patients' individual circumstances, and not the dictates of payors. For the last two years, almost all health systems have already effectively implemented clinical decision support mechanisms that comply with the AUC regulations.

Since the enactment of PAMA, CMS has taken multiple steps toward full implementation of this program. But the program's initial scheduled implementation date of January 2017 has been delayed four times. Will it finally go into effect in January of next year?

Expect to hear a lot about this debate during the remainder of 2022.