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Medicare Appropriate Use Criteria Program

NOTICE: CY 2021 is an EDUCATIONAL AND OPERATIONS TESTING PERIOD for the AUC Program. There are no payment consequences associated with the AUC program during CY 2021. CMS encourages stakeholders to use this year to learn, test and prepare for the AUC program.



Background

The Protecting Access to Medicare Act of 2014 (PAMA) (P.L. 113-93) established an appropriate use criteria (AUC) program for advanced diagnostic imaging services provided to Medicare beneficiaries. Physicians and other health care professionals who order an advanced diagnostic imaging test will be required to first consult a qualified Clinical Decision Support Mechanism (CDSM) to determine if the test ordered is appropriate, not appropriate, or if it is not covered by the software. Professionals who furnish these tests must document the ordering professional’s consultation of AUC on the Medicare claim to be paid for the service. The law also directs the Centers for Medicare & Medicaid (CMS), after collecting sufficient claims data, to require prior authorization for up to 5 percent of outlier ordering professionals.


MGMA Resources and Advocacy

  • November 27, 2020: MGMA joins effort calling for reevaluation of the CMS Appropriate Use Criteria program
  • November 7, 2020: MGMA and coalition urge Congress to delay AUC program
  • MGMA AUC Toolkit
  • Advocacy Letter: MGMA and other provider groups ask Congress for AUC program relief
  • Sept. 2018 MGMA press release calling for AUC program relief
  • MGMA Medicare Physician Fee Schedule (PFS) comments on AUC (pgs. 13-20)


CMS Resources

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