CMS postpones 'appropriate use' mandate past 2021

By Brian Casey, AuntMinnie.com staff writer

August 11, 2020 -- Clinicians ordering advanced imaging scans like CT, MRI, and PET in the Medicare system will no longer have to use appropriate use criteria (AUC) and decision support starting in 2021. On August 10, the U.S. Centers for Medicare and Medicaid Services (CMS) said it was extending the testing period for AUC through the end of 2021.

CMS has been looking for ways to reduce inappropriate utilization of advanced imaging services, and it has settled on appropriate use and decision support as one of the ways to do so. In principle, referring physicians would reduce their orders for clinically unnecessary exams if they were only able to order them using decision-support software based on AUC guidelines.

Implementing appropriate use has been easier said than done, however. Appropriate use and decision support were finally mandated as part of the Protecting Access to Medicare Act (PAMA) in 2014. Under PAMA, payment for radiological services could be denied if MRI, CT, PET, and nuclear medicine scans were not ordered using a clinical decision-support mechanism (CDSM) that has been approved by CMS.

But given that decision support represented such a major change to physician ordering habits, CMS gave referring doctors and radiologists a long lead time to put the mechanisms in place. They could start participating on a voluntary basis beginning in July 2018, and CMS stated that 2020 would be a year for education about appropriate use and testing of ordering mechanisms. Full implementation -- and denial of payments -- was scheduled to start in January 2021.

The August 10 announcement changes all that. In a note on the CMS website, the agency states that the educational and operations testing period for appropriate use will be extended through calendar year (CY) 2021.

"There are no payment consequences associated with the AUC program during CY 2020 and CY 2021," the CMS notice states. "We encourage stakeholders to use this period to learn, test and prepare for the AUC program."


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