Frequently Asked Questions
What is Appropriate Use Criteria (AUC)?
Appropriate Use Criteria (AUC) is a Medicare mandate. This mandate originates from the Protecting Access to Medicare Act of 2014 (PAMA). It requires an ordering provider to consult a Clinical Decision Support Mechanism (CDSM) when ordering specific advanced diagnostic imaging for Medicare outpatients. January 2020 starts an operational and testing year and full implementation begins January 2021.
When do the Providers Need to Consult a Clinical Decision Support Mechanism (CDSM)?
Providers need to consult a CDSM when:
Placing an outpatient advanced imaging order for Medicare B patients.
Advanced imaging test that are currently included in this mandate are CT, MRI/MRA, NM and PET scans.
Outpatient includes: Physician offices, emergency departments, ambulatory surgical centers and independent diagnostic testing facilities.
What if my physician office’s Electronic Health Record does not have a CDSM?
Free portal access to CareSelect (Randolph Health’s CDSM) is available to any provider who is ordering outpatient advanced imaging for Medicare patients at Randolph Health. To register for the portal click here and create an account. There is also a video on the Randolph Health website (where this FAQ document was found) that will show providers how to use the portal. If you physician’s office continues to have difficulty with this new process, then please email us at AppropriateUseCriteria@randolphhealth.org for further assistance.
Why is AUC Required?
AUC is being required by Medicare. It is designed to facilitate ordering the most appropriate test for specific indications, thus reducing unnecessary radiation exposure and minimizing repeat testing.
Where do the indications come from?
CareSelect’s (Randolph Health’s CDSM) content is evidence-based, up-to-date information that has been developed by professional organizations (American College of Radiology, Society of Nuclear Medicine, Pediatric Radiology and the National Comprehensive Cancer Network). Subject matter experts from each specialty have participated to ensure relative indications for each specialty have been included.
What if I disagree with the exams that are being suggested?
As a provider, you can still select the original intended exam by confirming this selection regardless of the score. A pop-up will appear for low scoring exams (1-3 or not appropriate) to collect information on why the exam was selected. This information is collected and will be reviewed for future content updates.
Does this mean I no longer need to get pre-authorizations?
No. AUC is completely separate from pre-authorizations. If a patient would have required a pre-authorization before AUC, then they will continue to require pre-authorization in the future. Also, receiving a high score for AUC does not mean that an exam will be authorized. AUC and pre-authorizations are not related.
What are Priority Clinical Areas?
CMS has chosen the eight priority areas below that may be used to identify outlier ordering providers. Information on how CMS will determine outlier ordering providers has not yet been released. The most updated list can be found here.
- Coronary artery disease (Suspected or diagnosed)
- Suspected pulmonary embolism
- Hip pain
- Low back pain
- Shoulder pain
- Cancer of the lung (primary or metastatic, suspected or diagnosed)
- Cervical or neck pain
What information do providers need to send with the order?
- Name of which CDSM vendor was consulted (there are multiple CDSMs that are approved and available).
- ID number generated by CDSM if available.
- Appropriate or Not Appropriate - Whether the advanced diagnostic imaging (CT,MRI/MRA,NM & PET scan) is listed as appropriate or not appropriate.
- Score – number score (1-9 or No Score) given by CDSM. This score is needed if the appropriateness (Appropriate or Not Appropriate) is unavailable.
Exceptions to consulting a CDSM for AUC
- Emergency services for patients with specific medical conditions as defined here.
- AUC information is not required for Inpatients and patients using Medicare Part A.
- Ordering professionals, when experiencing a significant hardship which includes:
- Insufficient internet access
- EHR or CDSM vendor issues
- Extreme and uncontrollable circumstances
For additional questions or concerns please email: AppropriateUseCriteria@randolphhealth.org