Appropriate Use Criteria - Part II

Appropriate Use Criteria (AUC) has become a mandatory program starting January 2020. The Centers for Medicare & Medicaid Services (CMS) considers 2020 as a year of “Education and Operations Testing Period” with full implementation set to be January 2021. During this timeframe, missing AUC claims data will not cause denied claims.

This program is dovetailed into the Merit-Based Incentive Program System (MIPS). While MIPS affects professional services, the AUC program will require the rendering provider to submit claims-based data for reporting purposes. A rendering provider is considered a hospital, ambulatory surgery center, or independent diagnostic treatment facility (IDTF). The payment systems affected are the Medicare Physician Fee Schedule, Outpatient Prospective Payment System, and the Ambulatory Surgical Center Payment System. Rendering providers reimbursed under different payment systems are exempt from reporting at this time, eg, Critical Access Hospitals (CAH).

Specific clinical indications, such as coronary artery disease that is suspected or diagnosed, have been designated under the Priority Clinical Areas. Advanced diagnostic imaging services include computed tomography (CT), positron emission tomography (PET), nuclear medicine, and magnetic resonance imaging (MRI). The specific advanced diagnostic imaging services with the priority clinical areas make up approximately 40% of all advanced imaging services.

Are you ready for this update? How did we get here? Who is supposed to do what? The old Abbott & Costello routine of “Who’s on First” comes to mind, as it can be confusing at first. Join us for our one-hour webinar as we provide an update and overview into the answers for those who, what, where, when and why questions.