Preparing for the 2022 CMS Appropriate Use Criteria Program Final Rule

CMS Appropriate Use Criteria Program

After several months of delays, CMS is finally getting the Appropriate Use Criteria Program AUC Final Rule back on track in time for CY 2022. With a start date of January 1st, 2022, compliance with the ruling will have major financial and operational implications on medical practices right at the start of the year.

Backtrack: What exactly is going on?

As of January 1st, 2022, organizations that order advanced diagnostic imaging services as part of Medicare Part B will need to go through an AUC consultation via a CMS-qualified Clinical Decision Support Mechanism (QCDSM). This means that any claims that are submitted to CMS for advanced diagnostic imaging and radiology procedures will need to show proof that a care provider consultation was performed by a CMS-approved CDSM. If a consultation is not made, the claims will not be paid by CMS, and reimbursement for the radiologist is not possible. 

Background and Context

The Medicare AUC program was established by the Protecting Access to Medicare Act (PAMA) in 2014 that sought to provide beneficiaries with advanced diagnostic imaging services like CT, PET, Nuclear medicine, and MRI scans.

At the moment, the AUC program is operating in an Education and Operations Testing Period that began on January 1st, 2020. During this time, claims are not being denied for failing to include the proper AUC consultation information.

How radiologists can reap financial rewards – CMS Appropriate Use Criteria Program

Having an AUC consultation with a CMS-qualified CDSM will be the main priority for image furnishing facilities to avoid penalties in 2022. While CY 2021 was an educational year to test operations as well as an extension from the embattled CY 2020, radiologists should not expect the same kind of leniency moving forward. In fact, furnishing facilities will want to take a closer look at high-priority CDSM diagnostic imaging areas including:

  • Coronary artery disease
  • Suspected pulmonary embolism
  • Headache
  • Hip pain
  • Low back pain
  • Shoulder pain
  • Cancer of the lung (primary or metastatic, suspected or diagnosed)
  • Cervical or neck pain
Claims and Payment Systems

In order for CMS to reimburse diagnostic imaging services furnished in medical facilities and care settings, radiologists will need to append AUC consultations with:

  • Physician fee schedule
  • Outpatient prospective payment system
  • Ambulatory surgical center payment system
Accurate coding

Accurately relaying consult results via HCPCS modifiers and G Codes that define CMS-approved vendors will pave the way towards key CMS reimbursements. Additionally, understanding the exemptions to the CMS rules like pregnancies and emergency situations will also help to save time in addition to working with the right CDSM partner. 

Picking the right partner makes all the difference

Care providers aren’t required to submit QCDSMs in order to get CMS benefits. Furnishing facilities, however, are. That means the onus is on the radiologist to get the care facility to add another step into the workflow in order to receive the full benefits.

This is where the AUC module in the Persivia CareTrak™ application comes into play. By partnering with Persivia, radiologists can assure ordering provider workflows are as quick and painless as possible. Thanks to CareTrak’s™ cloud-based CDSM, providers can receive a set of recommendations after submitting a clinical indication. From here the provider can select the best imaging decision for the patient and push it back through the EHR where the imaging facility will be provided with an AUC certificate as well as an NPI number. This certificate can then be used by the imaging team as proof for CMS’ end-of-year reimbursements.

While the penalty period has been delayed until January 2023, radiologists will still want to get a head start on the new AUC certification process. By partnering with Persivia Clinical Decision Support (G1023), radiology teams can rest assured that they are making the best decision when it comes to selecting a CDSM for ordering care teams.

Time is running out for compliance with the 2022 AUC Final Rule. Contact us for a demo today!