The Protecting Access to Medicare Act, passed by Congress in 2014, included a provision requiring that clinicians consult appropriate use criteria (AUC) through a qualified clinical decision support mechanism (CDSM) when ordering advanced imaging services (i.e., SPECT/PET MPI, CT and MR) in order to receive payment approval from the Centers for Medicare and Medicaid Services (CMS).

In the years since the passage of the Act, CMS has delayed the implementation of this consultation requirement until Jan. 1, 2020, while developing additional regulations and instructions on how ordering and imaging professionals are to participate in the program.

Of note, only entities meeting qualified "provider-led entity" (PLE) standards, like the ACC, can develop AUC for use in the program. In addition, the 2017 Medicare Physician Fee Schedule established requirements and processes for specification of qualified CDSMs. The College has been working to license its AUC content to qualified CDSMs in order to ensure its AUC is available to members.

In other recent milestones, CMS has designated AUC consultation through a CDSM as an Improvement Activity under the Merit-Based Incentive Payment System (MIPS), part of the Quality Payment Program. Provisions included in the 2019 Medicare Physician Fee Schedule:

• Require the use of forthcoming HCPCS G-codes and modifiers to report required AUC information on Medicare claims for both the technical and professional components;
• Allow delegation of AUC consultation with a qualified CDSM to clinical staff working under the direction of the ordering professional;
• Revise the significant hardship criteria to include insufficient internet access, electronic health record (EHR) or CDSM vendor issues, or extreme and uncontrollable circumstances.

While reporting will be required starting on Jan. 1, 2020, it will be an educational year during which CMS will not deny claims through Dec. 31 that incorrectly report AUC information.

With 2020 fast approaching, ACC leaders and staff are working to educate providers about the mandate and prepare them for the potentially significant change to their practice workflow. Cardiovascular professionals should be holding planning discussions with their practice, cardiovascular business line and health systems to understand which AUC content and decision support vendors are, or will be, used.

A recent CardioSurve survey of ACC members found most cardiologists are not prepared for the mandate, with only one out of 10 even aware of which CDSM their organization is using. Across practice types, cardiologists in cardiovascular or multi-specialty practices are slightly more likely to be prepared for the AUC mandate (30 percent) as compared to those in hospitals or medical schools (18 percent). On a positive note, nearly half of cardiologists familiar with the mandate believe that clinical decision support will be very/extremely useful.

In addition to educating members, the ACC also continues to work with CMS to fine-tune and implement the program. In addition, the College is encouraging CMS and Congress to consider "accomplishing the goals of the AUC program through existing programs, such as the Quality Payment Program," noting this would present "a less burdensome approach to both clinicians and the agency." However, to do this would require action by Congress, as well as further refinements through the rulemaking process.

Learn more about the AUC Mandate at ACC.org/Focus. Click here to review a list of ACC's CDSM partners.

Keywords: ACC Publications, Cardiology Magazine, Health Policy, Healthcare Common Procedure Coding System, Centers for Medicare and Medicaid Services, U.S., Motivation, Decision Support Systems, Clinical, Goals, Medicare, Medicaid, Schools, Medical, Workflow, Fee Schedules, Area Under Curve, Electronic Health Records, Referral and Consultation, Tomography, Emission-Computed, Single-Photon, Tomography, X-Ray Computed

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