AHA Urges CMS to Hit Pause on Appropriate Use Criteria


The Protecting Access to Medicare Act of 2014 required CMS to initiate the use of appropriate use criteria (AUC) for advanced diagnostic imaging beginning Jan. 1, 2017, but the agency used the 2016 Medicare Physician Fee Schedule (MPFS) rule to delay implementation indefinitely, pending the approval of both the AUC and the mechanisms that could be used to implement the program.

The suspense ended with the Proposed 2017 MPFS rule, published in July, in which CMS provided stated that the first clinical decision support mechanisms (CDSMs) will be approved on June 30, 2017. The agency also said it expects furnishing professionals—radiologists, cardiologists, orthopedists and other providing entities—to begin reporting on AUC consults by January 1, 2018.

In its comments on the rule, the American Hospital Association has asked CMS to reconsider that Jan. 1, 2018, start date, suggesting that six months from mechanism approval to implementation does not leave hospitals enough time to prepare. AHA asked CMS to delay the payment reduction associated with failure to consult AUC until no less than 12 months from the date the CDSMs are approved.

“…the potential timeframe described by CMS leaves providers very little time…to acquire access to and deploy qualified CDSMs,” the AHA comment letter states. “Specifically, providers will need time to determine which entity or entities has the relevant criteria set for a physician’s patient base.”

Radiologists are well advised to prepare to weigh in on that subject, since both technical and professional payment will depend on being able to provide proof that AUC was consulted prior to imaging Medicare and Medicaid patients.