Starting Jan. 1, CMS will implement new appropriate-use criteria for advanced diagnostic imaging services provided in ASCs, physician offices and other applicable settings.
Seven things to know:
1. CMS began allowing voluntary participation in the AUC program in July 2018. Participation will become mandatory on Jan. 1, 2020, when a new testing period begins.
2. The AUC set to take effect in 2020 will require professionals to consult a clinical decision support mechanism before ordering Medicare Part B advanced diagnostic imaging services. A CDSM is an electronic tool that will tell ordering clinicians whether their order adheres to AUC.
3. Claims won't be denied during the 2020 testing period. But starting Jan. 1, 2021, in order for claims for imaging services to be paid, those claims must include information regarding consultation with CDSM.
4. The change applies to certain imaging services provided in ASCs, physician offices, independent diagnostic testing facilities and hospital outpatient departments, and to services paid under the physician fee schedule, hospital outpatient prospective payment system and the ASC payment system.
5. CMS will make exceptions to the CDSM requirement in cases where the ordering professional has "significant hardship," the patient has an emergency medical condition, or the imaging service is ordered for an inpatient and meant for payment under Medicare Part A.
6. Eventually, CMS will use data collected from the program to identify providers with "outlier-ordering patterns." Those professionals will be subject to prior authorization when ordering advanced diagnostic imaging services.
7. Ahead of the changes, the Medical Group Management Association published information on how AUC might alter practice workflows and what practices can do to prepare. Click here to access the toolkit.