Appropriate Use Criteria Program

Background

The Protecting Access to Medicare Act (PAMA) of 2014, Section 218(b), authorized a 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. The CDSM provides a determination of whether the order adheres to AUC, or if the AUC consulted was not applicable (e.g., no AUC is available to address the patient’s clinical condition). A consultation must take place at the time of the order for imaging services that will be furnished in one of the below settings and paid for under one of the below payment systems.  Ultimately, practitioners whose ordering patterns are considered outliers will be subject to prior authorization.  Information on outlier methodology and prior authorization is not yet available. 

This program impacts all physicians and practitioners (as defined in 1861(r) or described in 1842(b)(18)(C)), that order advanced diagnostic imaging services and physicians, practitioners and facilities that furnish advanced diagnostic imaging services in a physician’s office, hospital outpatient department (including the emergency department), an ambulatory surgical center or an independent diagnostic testing facility (IDTF) and whose claims are paid under the physician fee schedule, hospital outpatient prospective payment system or ambulatory surgical center payment system.

Program Timeline

• In the CY 2024 PFS Final Rule (November 16, 2023), CMS paused implementation of the AUC program for reevaluation and rescinded the AUC regulations at 42 CFR 414.94. CMS has not specified a timeframe within which implementation efforts will recommence. See pages 79256-79265 of the final rule (link below).
• In 2023, on this website, CMS announced that the Education and Operations Testing Period would continue until further notice and that the penalty phase would not begin on January 1, 2023, even if the PHE ended in CY 2022.
• In the CY 2022 PFS Final Rule (November 2021), CMS further delayed full implementation until the later of January 1, 2023 or the January 1 that follows the declared end of the public health emergency (PHE) for COVID-19.
• In July 2020, in response to the COVID-19 PHE, CMS extended the Education and Operations Testing Period.
• Beginning January 1, 2020, the program operated in an Education and Operations Testing Period, during which claims will not be denied for failing to include proper AUC consultation information.
• From July 1, 2018 through December 31, 2019, the program operated under a voluntary participation period during which time consultations with AUC that occurred were reported on furnishing professional and facility claims using HCPCS modifier QQ.

Rules and Regulations

The CY 2024 PFS Final Rule (pages 79256-79265) paused implementation of the AUC program and rescinded the regulations at 42 CFR § 414.94, effective January 1, 2024.

The CY 2022 PFS Final Rule (pages 65224-65241) included further updates.

The CY 2019 PFS Final Rule (pages 59688-59701 and page 60074) included further updates.

The CY 2018 PFS Final Rule included requirements for consulting and reporting under the Medicare AUC program (pages 53187-53201 and page 53363).

The CY 2017 PFS Final Rule (pages 80403-80428 and pages 80554-80555) included additional updates to the program.

The CY 2016 Physician Fee Schedule (PFS) Final Rule with Comment Period introduced this program (pages 71102-71116 and pages 71380-71382).

Questions regarding this program may be submitted to the CMS Imaging AUC resource box: ImagingAUC@cms.hhs.gov.