This browser is not actively supported anymore. For the best passle experience, we strongly recommend you upgrade your browser.
Welcome to Reed Smith's viewpoints — timely commentary from our lawyers on topics relevant to your business and wider industry. Browse to see the latest news and subscribe to receive updates on topics that matter to you, directly to your mailbox.
| 1 minute read

Full implementation of Medicare advanced imaging appropriate use criteria program indefinitely delayed

The Centers for Medicare & Medicaid Services (CMS) has announced an indefinite delay in the penalty phase of the program to require physicians and other practitioners who order an advanced diagnostic imaging service for a Medicare beneficiary to consult appropriate use criteria (AUC) via a qualified Clinical Decision Support Mechanism (CDSM). The AUC program had been set to be fully implemented on the later of January 1, 2023 or the January 1 that follows the declared end of the public health emergency (PHE) for COVID-19.

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 had 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 to 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 CMS announcement states that the payment penalty phase will not begin January 1, 2023 even if the PHE for COVID-19 ends in 2022. Until further notice, according to CMS, the educational and operations testing period will continue. CMS indicated that it is "unable to forecast when the payment penalty phase will begin."

Clearly, those who have created the drumbeat of calls to repeal or delay this Medicare program have a big win!

Beginning July 1, 2018 the program operated under a voluntary participation period during which time consultations with AUC that occured were reported on furnishing professional and facility claims using HCPCS modifier QQ.


health care & life sciences, diagnostic radiology, auc