The Centers for Medicare & Medicaid Services (CMS) just released a new transmittal for Medicare Administrative Contractors (MACs) to put fully into place the agency's suspension of the Appropriate Use Criteria for Advanced Diagnostic Imaging (AUC) program. The action to pause the AUC program occurred when the CY 2024 Medicare Physician Fee Schedule (MPFS) final rule went into effect on January 1, 2024.

The AUC Program was first enacted by Congress in the Protecting Access to Medicare Act of 2014 (PAMA).  Congress had sought to gain savings in Medicare spending by mandating the assessment of the need for the more costly outpatient advanced diagnostic imaging studies (computed tomography, positron emission tomography, nuclear medicine, and magnetic resonance imaging) when those studies were ordered for Medicare beneficiaries. The AUC program required ordering physicians for these tests to use clinical decision support mechanisms (CDSM) to consult appropriate use criteria developed by peer medical organizations approved by CMS to assure that only the right study be performed. But CMS was never able to fully implement AUC.  Since 2020, the program has operated in an educational and operations testing mode only during which no payment penalties were ever put in place. 

Implementation of the AUC program had faced considerable hurdles due to the process used to review ordering physician adherence to AUC consultation. Enforcement has focused on the Medicare claims for payment filed for outpatient advanced imaging by the imaging providers and suppliers who performed those tests. With upside down logic, the AUC program designed by CMS imposed penalties for failure to consult appropriate use criteria on imaging providers/suppliers who received orders for those tests -- not on the non-complying ordering physicians. And the means of monitoring compliance never overcame built in administrative clumsiness. 

Consequently, in the 2024 MPFS final rule, CMS announced that the Medicare claims processing system just did not have the capacity to fully automate the process for monitoring compliance. Their AUC program using advanced diagnostic imaging claim remittances was suspended.

Providers and suppliers of advanced imaging services will no longer need to include AUC consultation information on MPFS claims. CMS intends to terminate the HCPCS G Codes and Modifiers that have been used to make reports of AUC consultation, but not until year end to allow final claims with dates of service of 2023 and 2024 to be adjudicated though that period. CMS has asked MACs to continue to process Medicare claims for advanced diagnostic imaging services containing those G codes and modifiers until December 31 so that providers and suppliers will have time to adjust their internal operations and claims systems accordingly.

Thus, MACs are instructed to have removed all national and local edits related to the AUC program and to have discontinued their use as they process claims for outpatient advanced diagnostic imaging tests with dates of service on or after January 1, 2025.

Done and done!