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APPROPRIATE USE CRITERIA- Will you be ready? The time is NOW

APPROPRIATE USE CRITERIA- Will you be ready? The time is NOW

05/03/2019  |  Lois Stewart-Wiebe, APS Client Service Manager

Most radiology practices are aware to some extent of this latest reporting requirement from CMS.  Some refer to it as the Clinical Decision Support (CDS), others Appropriate Use Criteria (AUC), but like Shakespeare's "rose by another name," they are the same.  While it may seem months away, there is a lot to digest to be adequately prepared. 

In a nutshell, the ordering/referring provider must consult an approved appropriate use database when ordering advanced imaging, and document on the order that he/she has done so.  Included in that order is an indication of which database was consulted, and whether the criteria is met or not.  A list of qCDSMs can be found here:  CMS qCDSMs

2020 is the 1st year when it will be required on all advanced imaging claims, with only 3 exceptions, in-patient, emergency, and significant hardship.  2020 is the 1st year where there providers will be required to report, but it is considered a testing year.  


As of now, providers will report with a G-code on the claim to identify the qCDSM consulted, and a modifier to indicate if the criteria was met or not met. Since this is intended to be an educational program and not a precertification process, radiologists will not be penalized for the “not met” modifier. 

Implementation: While this appears to be straightforward, the devil is in the details. There are several steps to consider in the process including any technology modifications, program education for referring providers, and how to report this new data element on the claims.

Technology: 

  • Where will this information go on an electronic order? 
  • How will it be transferred to the report or to the radiologist?
  • Will any interfaces require modification?
  • For Hospital based providers, how will they transfer this information to the radiology billing offices?  

Referring Provider Education:

  • Help educate your referring providers on the program.  Work with them on solutions.  
  • Supply a resource of databases if they don't have access to them already.  

Claims Filing:  

  • Where will this information go on the claim?
  • What if the ordering provider does not send the required information?  Since 2020 is an outreach year, the claims will still be processed.  However in 2021, they will not be accepted without the required information.  

What can you do now? 

  • Start the conversation with your referring providers as early as possible. 
  • Reach out to your RIS/EHR vendor to learn what solutions are available and what is being worked on.  
  • If you are a hospital-based practice- stay engaged with the hospital administration and IT team to be sure you get the data you need where you need it. 
  • Keep an eye on the developing information/instructions coming from CMS on the topic.  

Where can you learn more on this topic:  Here is a link to the CMS page on the program.  CMS AUC PROGRAM

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