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CMS Delays Full Implementation of Appropriate Use – Again


Referring physicians will have until after 2021 to adopt appropriate use criteria and clinical decision support.

As anticipated would happen by many in the industry, the Centers for Medicare & Medicaid Services (CMS) announced this week it is pushing back the mandate for referring providers to use appropriate use criteria (AUC) and clinical decision support (CDS) tools. Now, the testing period for physicians who order advanced imaging scans has been extended through the end of 2021.

CMS announced the AUC educational and operations testing period extension through calendar year 2021 in an Aug. 10 statement. During this time, providers can continue to explore and familiarize themselves with the system without fear of any financial impact.

“There are no payment consequences associated with the AUC program during [calendar year] 2020 and [calendar year] 2021,” the agency said in its announcement. “We encourage stakeholders to use this period to learn, test, and prepare for the AUC program.”

Related Content: RBMA: What You Need to Know About Looming Appropriate Use Criteria Implementation

Under these guidelines, once implemented, any referring provider will be required to consult a CDS tool before officially ordering a CT, MRI, or PET can for a Medicare patient. Overall, they can proceed with the order if the CDS determines the study would be clinically appropriate. This system, once fully engaged, is designed to control unnecessary imaging utilization.

AUC was first proposed as part of the Protecting Access to Medicare Act of 2014. Once the mandate is finally enacted, referring provider compliance will be financially critical for radiologists – if ordering physicians do not comply and consult a CDS before sending a patient for advanced imaging, payment for the radiologist services used to conduct an MRI, CT, or PET scan will be denied.

But, getting the mandate off the ground has been difficult with several delays over the past five years. The latest plan allowed referring physicians to voluntarily participate in AUC beginning in July 2018. CMS agreed to treat the next two years as a trial period, offering education and allowing providers to make and correct mistakes on claims without fearing reimbursement denials. The program was set to finally go into effect in January 2021.

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