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CMS Pushes Timeline for Imaging AUC Back Six Months

August 24, 2016:

The Centers for Medicare and Medicaid Services (CMS) included details about the appropriate use criteria (AUC) program for advanced diagnostic imaging services in its proposed rule for the Medicare physician fee schedule for calendar year 2017, published in mid-July. It particularly focused on clinical decision support mechanisms (CDSM), which clinical areas would be prioritized, and exceptions to the requirement that the ordering professional apply AUC when ordering imaging services. The agency also noted that several implementation dates will have to be pushed back at least an additional six months.

The AUC, stipulated by the Protecting Access to Medicare Act of 2014, will affect a huge number of clinicians because they will apply to every practitioner who orders or provides applicable imaging services. The AUC provide a way for ordering physicians to know which advanced imaging service is most likely to lead to improved health outcomes based on a patient’s clinical presentation. Each individual criterion within the AUC is an evidence-based guideline for a specific clinical scenario. The AUCs ideally should be woven as seamlessly as possible into the clinical workflow.

The practitioners who provide the imaging services will be required to note on claims that the ordering physician consulted the AUC before selecting which imaging service to order. CMS has not yet decided how this information should be recorded.

Studies have shown that the use of AUC can significantly reduce the employment of certain procedures and increase the rate such services are used appropriately. The result is cost savings and better patient care. CMS believes the same will be true for diagnostic imaging services. One study published in the American Journal of Cardiology in April noted that UnityPoint Trinity, which operates four hospitals in Illinois and Iowa, saw a 17 percent drop in the use of percutaneous coronary intervention (angioplasty with stent) after it started using peer-reviewed AUC in 2012. The proportion of appropriate PCI rose to 84 percent from 76 percent, and reimbursement for PCIs fell 36 percent.

CDSMs: These are electronic portals that provide access to the AUC. They can be stand-alone applications requiring manual keying in of patient information, or they can be connected to a records system that automatically populates fields with information about patient characteristics, lab results, and comorbidities. In the July rule, CMS states that successful CDSMs will be flexible so that they can be used by practices of every type, size, and location.

Prioritized clinical areas: The following have been proposed as the first clinical areas to be required to use the AUC for identifying the most appropriate imaging service. Together, they account for approximately 47 percent of the total number of advanced imaging services provided:

• Chest pain (angina, suspected myocardial infarction, and suspected pulmonary embolism)

• Abdominal pain (any locations and flank pain)

• Headache, traumatic and nontraumatic

• Low-back pain

• Suspected stroke

• Altered mental status

• Cancer of the lung (primary or metastatic, suspected or diagnosed)

• Cervical or neck pain

Note that the following are qualified “provider-led entities.” Any AUC these PLEs develop, modify, or endorse are considered specified applicable AUC.

Qualified Provider Led Entities (PLEs) as of June 2016

• 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

Exceptions: There are three main exceptions to the requirement that physicians use AUC before selecting which advanced imaging service to order for a patient:

• Emergency services

• Inpatient Part A

• Undue hardship that would be caused by the requirement (for example, a physician in a rural area with no internet access)

Timeline: CMS offers the following key dates in its stepwise approach to implementing AUCs:

June 30, 2017 (rather than the previously proposed January 1, 2017): Post list of qualified CDSMs. This will give practitioners a chance to align themselves with the CDSM that best meets their needs.

January 1, 2018: Earliest date CMS foresees requiring furnishing practitioners to report AUC information (details on how to report the information on claims will be in the PFS proposed rule for 2018).

For more information on AUC and the proposed rule, go to a href="https://www.gpo.gov/fdsys/pkg/FR-2016-07-15/pdf/2016-16097.pdf">https://www.gpo.gov/fdsys/pkg/FR-2016-07-15/pdf/2016-16097.pdf


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