CMS Mandates Appropriate Use Criteria Consultation  [October 2018 Update]

Originally posted on Feb 16th, 2015 by Jim McGee, BS CNMT NCT

CMS Appropriate Use Criteria Mandate

Ordering physicians/providers are going to have to document Appropriate Use Criteria consultation at the time they order advanced diagnostic imaging.

Imaging labs are going to have to report that consultation on their claims to CMS – or they will not be reimbursed.

This was originally slated to start January of 2017.

This article updated October 2018:

  • The deadline for Appropriate Use Criteria Consultation & Reporting has been pushed back (again) to January 2020.
  • There are many medical associations (especially primary care associations) actively advocating for a repeal of the AUC Mandate, so it may never come to pass.
  • These associations argue that quality measures are already being incorporated into reimbursement (MACRA, QPP, MIPS & APMs), and that AUC should be incorporated into these programs.
  • CMS has published it’s initial list of qualified Clinical Decision Support (CDS) software vendors.
  • Click Here to View CMS’s List of Qualified CDS’s

PAMA: The Protecting Access to Medicare Act of 2014

PAMA (“PAM-uh”) was a temporary sustainable growth rate fix, postponing the SGR until April 1st, 2015.

PAMA directed CMS to require Appropriate Use Criteria (AUC) consultation for Advanced Diagnostic Imaging starting Jan 1, 2017.

(This has been delayed to January 1, 2020.)

Read about the Appropriate Use Criteria Mandate on the CMS website here.

Advanced Diagnostic Imaging Is:

  • Nuclear Medicine (Including Nuclear Cardiology & PET)
  • CT
  • MRI

These Are Not Advanced Diagnostic Imaging:

  • Ultrasound
  • Echocardiography
  • X-ray
  • Flouroscopy
  • Diagnostic & Screening Mammography

Ordering MDs Must Consult Appropriate Use Criteria:

CMS will require physicians who order advanced diagnostic imaging tests to document that they consulted Appropriate Use Criteria (AUC) when ordering.

This documentation must be present on the claim that the professional who performs the test  submits for Medicare reimbursement, or else that imaging laboratory / physician who performs the test will not be paid.

So the burden of implementation falls on ordering physicians, but the consequences of non-adherence will be experienced by imaging laboratories.

The ordering physician must use a qualified Clinical Decision Support tool (CDS) mechanism in his/her consultation of AUC.

CMS will determine which Appropriate Use Criteria are valid, and which CDS tools are qualified.  They released their first list of approved CDS systems by June 30th, 2017 (more on this below).

Cardiac Imaging that Will be Affected Includes:

  • Nuclear Cardiology
  • PET
  • CT
  • MRI
    • (Echocardiography is excluded)

So, if you’re a cardiology practice that orders & performs SPECT MPI procedures, then starting January 1st, whoever orders the test  must document AUC Consultation at the time they order the test.

If you wait until you bill to consult AUC, it will be too late, you won’t get paid by CMS if you do it that way.

The CDS mechanism will time/date stamp the AUC Consultation when it generates the “Unique Decision Support Number” for a particular test.

So you need to have a system in place before January 1st to document these AUC consultations through a qualified CDS.

CMS has indicated that there is going to be a free CDS mechanism.  Once I find out what that is, I’ll update this article.

Facilities Affected Will Include:

  • Physicians’ Offices
  • Independent Testing Facilities
  • Hospital Outpatient Settings
  • Emergency Departments

These Are Exempt:

  • Hospital inpatients
  • Emergency services as defined under the Emergency Medical Treatment and Active Labor Act (EMTALA)
  • Hardship exclusions, e.g. no access to high speed internet

Will CMS Reimburse “Inappropriate” Studies?


The CMS mandate will not, at least initially, result in hard denials of reimbursement for “inappropriate” / “rarely appropriate” studies.

However, CMS will immediately begin collecting data on referring physician’s patterns of adherence to AUC.  

CMS Prior Authorization:

Starting in 2020, CMS must use this data to identify up to up to 5% of physicians as being “outliers” in adherence to AUC.

Outlier physicians will be identified only for the following eight “clinical priority areas”:

  • Coronary Artery Disease
  • Suspected Pulmonary Embolism
  • Headache
  • Hip Pain
  • Low Back Pain
  • Shoulder Pain
  • Cancer of the Lung
  • Cervical or Neck Pain

Note: All advanced outpatient diagnostic imaging exams (not just those listed above) will require AUC consultation to qualify for CMS reimbursement.

However, the areas listed above are the only categories that CMS will be monitoring for patterns of adherence to AUC so that outlier physicians can be identified & subjected to prior authorization.  (That is because they represent ~ 40% of Medicare Imaging Volume)

Physicians identified as outliers in the above 8 areas will be subject to prior authorization starting in 2020.

Provider Led Entities:

CMS designates certain societies & organizations of medical practitioners as qualified “Provider Led Entities” (PLEs). In order to qualified by CMS, PLEs must adhere to an evidence-based process that is described in 42 CFR 414.94(c)(1) when they develop or modify their appropriate use criteria.

As of April 2017, these are all of the CMS-qualified Providers Led Entities (PLEs):

  • American College of Cardiology Foundation
  • American College of Radiology
  • Brigham and Women’s Physicians Organization
  • CDI Quality Institute
  • Intermountain Healthcare
  • Massachusetts General Hospital, Department of Radiology
  • National Comprehensive Cancer Network
  • Society for Nuclear Medicine and Molecular Imaging
  • University of California Medical Campuses
  • University of Washington Physicians
  • Weill Cornell Medicine Physicians Organization

(Click here to see the current list of PLEs on CMS website)

Once qualified by CMS, a PLE’s Appropriate Use Criteria are deemed “specified” AUC.

Those specified AUC are then eligible to be integrated into CMS- qualifed “Clinical Decision Support Mechanisms”, more commonly known as Clincial Decision Support Tools or CDS tools.

Clinical Decision Support Tools:

Clinical Decision Support (CDS) tools (or “mechanisms”) are software products that help practitioners make clinical decisions by consulting databases and appropriate use criteria- published by PLE’s (above).

Click Here to View CMS’s First List of Qualified CDS Tools

  • CMS has already specified some of the Provider Led Entities who are qualified to issue AUC guidelines (above).
  • CMS has published their first list of qualified Clinical Decision Support (CDS) software vendors.
  • This list will consist of 2 types of approved CDS Mechanisms (CDSMs):
    • Full Qualification CDSMs: (these will have demonstrated that they meet all of CMS’ requirements by the March 1, 2017 application deadline.
    • Preliminary Qualification: These CDSMs will have demonstrated that they meet most of the requirements by the application deadline, and they have also submitted a clear timeline regarding how they will meet all requirements by Jan 1, 2018.  If they don’t in fact stick to their timeline and meet all requirements by 1/1/2018, they will be de-qualified and they must notify all providers of their de-qualification.

Qualified Clinical Decision Support Mechanisms:

  • Applied Pathways CURION™ Platform
  • Cranberry Peak ezCDS
  • eviCore healthcare’s Clinical Decision Support Mechanism
  • National Decision Support Company CareSelect™
    • (Free tool available)
  • National Imaging Associates RadMD
  • Sage Health Management Solutions Inc. RadWise®
  • Test Appropriate CDSM

Clinical Decision Support Mechanisms with Preliminary Qualification:

  • AIM Specialty Health ProviderPortal®
    • (Free tool available)
  • Cerner CDS mechanism
  • Evinance Decision Support
  • Flying Aces Speed of Care Decision Support
  • LogicNets’ Decision Engines
  • MedCurrent OrderWise™
  • Reliant Medical Group CDSM
  • Siemens Healthineers Clinical Decision Support Mechanism
  • Stanson Health’s CDSM

Action Required Before January 2020:

At some point in the near future, ordering physicians are going to have to:

  • Research & purchase an approved CDS
  • Or make sure a qualified CDS is integrated into your EHR
  • There is a free option as well (see above)
  • Educate themselves and their mid-level providers on all advanced diagnostic testing AUC

And Imaging Laboratories need to coordinate with their Ordering MDs to make certain they are documenting AUC consults through an approved CMS.

The specific documentation requirements for Medicare billing have not yet been determined.  The final requirements will be made known in next year’s Medicare Physician Fee Schedule Final Rule.

However, the Medicare Physician Fee Schedule final rule for calendar year 2017 did specify that these 3 elements at a minimum will be required on claims for outpatient advanced diagnostic imaging:

  • CDS vendor
  • Whether the ordered test adheres to AUC Criterion or not (or if no criteria are applicable)
  • NPI number of Ordering Provider

CMS Has Yet to do the Following:

  • They have already selected some PLEs whose AUC guidelines will be accepted, but the list is not yet complete.
  • Determine specific documentation requirements.
  • Define the process and thresholds for identifying referring physicians as “outliers”

Practical Ramifications:

  • Practices which order advanced testing will need to integrate an approved CDS tool into their EHR relatively soon.
  • Ordering physicians will need to consult AUC through Clinical Decision Support tools prior to, or at the time of, ordering the imaging study.
  • Primary care physicians will experience the greatest burden, due to the broad variety of tests they order & the multiple corresponding AUCs they will have to be familiar with
  • This will raise challenges for workflow and information flow between referring physicians and imaging laboratories.
  • This could potentially disrupt referral patterns depending upon what the specific requirements are
  • Referring physicians will need to be more familiar with AUC, & all the more so for primary care physicians
  • Imaging laboratories should start becoming very familiar with AUC
  • Imaging laboratories should start developing systems to help their referring MDs select CDS tools, and use AUC for claims purposes
  • The 5% of physican outliers being subject to prior authorization starting in 2020 may very well signal the beginning of broader prior authorization requirements
  • It is not hard to imagine inappropriate studies being denied by CMS in the future
  • It is not hard to imagine other tests, procedures & treatments being similarly monitored & subject to CMS oversight in the future
    • In fact, PAMA requires the U.S. Government Accountability Office to conduct a study & issue a report by September 2015 about using appropriate use criteria for other services paid for by Medicare, specifically radiation therapy & clinical diagnostic lab services
      • This study / report may very well be simply a justification for what Congress hopes to do more of in the future

Jim McGee BA BS CNMT ARRT(N)(R) on LinkedinJim McGee BA BS CNMT ARRT(N)(R) on TwitterJim McGee BA BS CNMT ARRT(N)(R) on Youtube
Jim has been the Technical Director of an IAC Nuclear/PET nuclear cardiology lab for 11 years.

He originally developed the NucReporter to keep his own lab's reports 100% IAC compliant. But his interpreting physicians liked it so much, they encouraged him to commercialize it.

Jim's vision is to make affordable a world where all CNMTs & Cardiologists breeze through reports and go home earlier, while producing single-page nuclear stress test reports that are comprehensive, clear, concise, compliant & error-free.

What are your thoughts about appropriate use?