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Appropriate Use Criteria Program

The Protecting Access to Medicare Act (PAMA) requires that physicians ordering advanced imaging exams consult Appropriate Use Criteria (AUC) through a qualified Clinical Decision Support Mechanism (qCDSM).

January 1, 2020 marks the formal start of the program, where healthcare providers must consult qualified CDSM when ordering advanced imaging tests. Under the program, consultations must occur across all advanced imaging and evidence of consultation must be included on the claim. The consultation requirement applies to all Medicare Part B Advanced Diagnostic Imaging Services (CT, MR, NM, PET) across multiple care settings including outpatient and emergency departments.

Our Support

Providers can consult Clinical Decision Support (CDS) through a variety of resources. Sentara has partnered with National Decision Support Company, which offers a free web-based portal (CareSelect Imaging — Open Access), giving your practice access to the tools at no cost. Registration is simple and the tool is easy to use. To learn more, visit NationalDecisionSupport.com.

A Comprehensive Requirement

Ordering providers are required to consult AUC for all Medicare Part B Advanced Diagnostic Imaging Services (CT, MR, NM, PET). Consultation is required in all applicable settings as outlined by CMS. These include physician offices, hospital outpatient departments (including emergency departments), ambulatory surgical centers, and independent diagnostic testing facilities.

Physician Measurement & Priority Clinical Areas

CMS has outlined six Priority Clinical Areas (PCAs) as a baseline of clinical coverage to measure outlier physicians. Outlier calculation will be based on AUC adherence within the PCAs and applicability of the AUC to the service. In addition to outlier calculation, the PCAs serve as a good guide to begin your implementation.

Current PCAs include:

  • Coronary artery disease (suspected or diagnosed)
  • Suspected pulmonary embolism
  • Headache (traumatic and non-traumatic)
  • Hip pain
  • Low back pain
  • Shoulder pain (to include suspected rotator cuff injury)
  • Cancer of the lung (primary or metastatic, suspected or diagnosed)
  • Cervical or neck pain

Download the Centers for Medicare & Medicaid Services Appropriate Use Criteria for Advanced Diagnostic Imaging Fact Sheet

Download the Sentara Clinical Decision Support Fact Sheet

Sources:

  • https://nationaldecisionsupport.com/
  • https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/index.html