The Medicare AUC Program
Diagnostic imaging tests grew more rapidly than any other type of physician service from 1999 to 2004. This volume growth, combined with anomalies such as regional variances in rates of imaging stress tests for Medicare enrollees, spurred action from the US federal government.3,4
The Protecting Access to Medicare Act of 2014 directed CMS to establish a program promoting the use of AUC for advanced diagnostic imaging services. When fully implemented, this federal mandate will require providers to consult a qualified Clinical Decision Support Mechanism (CDSM) to help determine whether their orders for advanced imaging tests adhere to applicable AUC.2,5
Who Will Be Affected?
Anyone who orders or provides advanced imaging tests will be affected.1,2
- Ordering professionals will be required to consult applicable AUC using a qualified CDSM
- Furnishing professionals will be required to report on AUC consultation in Medicare claims
Which Tests Are Specified?
AUC will have to be consulted and documented to receive Medicare reimbursement for the following advanced imaging tests1:
- Nuclear medicine
- Computed tomography (CT) scanning
- Magnetic resonance imaging (MRI)
- Positron emission tomography (PET)
When Is the Deadline?
Phase 1. Educational and Operations Testing Period: January 1, 2020, to December 31, 2022, or the December 31 that follows the declared end of the public health emergency for COVID-19, whichever is later.1,2,a
- Providers are expected to consult the AUC and report utilization
- Claims will not be denied for failing to include AUC-related information (eg, CDSM G-code, Healthcare Common Procedure Coding System modifiers) on claim forms, but inclusion is encouraged
Phase 2. Full implementation: currently set for January 1, 2023, or the January 1 that follows the declared end of the public health emergency for COVID-19, whichever is later.1,a
- Providers are required to consult the AUC and report utilization in order to be reimbursed by Medicare for advanced imaging services
- Outlier ordering patterns will result in prior authorization
aDetails regarding the Medicare AUC program, including the implementation date, are subject to change without notice based on updates issued by CMS.
Which AUC Are Applicable?
CMS has identified a list of qualified provider-led entities that have developed applicable AUC. One of these is the American College of Cardiology Foundation (ACCF), which helped develop the Multimodality AUC for Stable Ischemic Heart Disease.6,7
Although qualified CDSMs have been selected, there are several point-of-care tools currently available. These tools are not yet classified as qualified CDSMs, but they can help identify which noninvasive cardiac imaging tests may be appropriate for patients at risk for CAD, using the applicable Multimodality AUC.