Effective January 1, 2020, CMS expects ordering providers to begin consulting qualified clinical decision support mechanisms (CDSMs) prior to ordering advanced imaging services in applicable settings for Medicare patients and providing information to the furnishing provider for reporting on their claims.

January 1, 2020, marked the start of the AUC program educational and operations testing period, at which time we began accepting AUC-related modifiers on claims for advanced diagnostic imaging services furnished to Medicare beneficiaries. During this phase of the program, we will not deny claims for failing to include AUC-related information or for misreporting AUC information on non-imaging claims.

Background

The Protecting Access to Medicare Act (PAMA) of 2014, Section 218(b), established a new program to increase the rate of appropriate advanced diagnostic imaging services provided to Medicare beneficiaries. Examples of such advanced imaging services include:

• computed tomography (CT)
• positron emission tomography (PET)
• nuclear medicine, and
• magnetic resonance imaging (MRI)

Under this program, at the time a practitioner orders an advanced diagnostic imaging service for a Medicare beneficiary, he/she, or clinical staff acting under his/her direction, will be required to consult a qualified Clinical Decision Support Mechanism (CDSM). CDSMs are electronic portals through which appropriate use criteria (AUC) is accessed.

Resources

• CMS AUC Program
• MLN AUC Fact Sheet
• MM11268