CMS testing diagnostic imaging referrals program in preparation for mandate

The Centers for Medicare & Medicaid Services (CMS) has begun testing a new program that affects referrals for advanced diagnostic imaging. Under the Appropriate Use Criteria (AUC) program, clinicians who order tests such as CT, MRI, PET, and nuclear medicine for Medicare beneficiaries will first be required to consult a qualified Clinical Decision Support Mechanism (CDSM) through an electronic portal to confirm the order fits the criteria for appropriate use.

The AAFP is advocating repeal of this mandate, which is scheduled to go into effect Jan. 1, 2021. But the testing of the AUC program has already begun. CDSMs can be consulted throughout 2020 and the HCPCS code entered onto the claim for educational purposes. Payment will not be denied this year if it is not present, however, some advanced imaging providers are indicating they will not perform the tests if this information is not provided.

CMS has a list of qualifying CDSMs here: https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/appropriate-use-criteria-program/CDSM

There are currently three free options. There may also be options available through your certified electronic health record (EHR).

The CDSM consulted will inform the ordering clinician if the advanced imaging tests ordered adhere to AUC. The ordering clinician then provides those clinicians furnishing the tests with his or her NPI, the name of the CDSM consulted, and if the test adhered to the AUC. This information must be entered on the furnishing professional’s Medicare claim to be paid for the test.

The AUC program was established by the Protecting Access to Medicare Act of 2014 (PAMA). Initially, it was mandated to begin in 2017, but the program has been difficult to operationalize.

—  Amy Mullins, MD, AAFP Medical Director, Quality and Science