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Appropriate Use Criteria Guidelines In Effect January 1, 2021

As of January 1, 2021, providers who serve Medicare patients will be required to consult a Clinical Decision Support Mechanism (CDSM) and obtain a determination as to whether the test conforms to the Appropriate Use Criteria (AUC) before the test can be administered.

Advanced diagnostic imaging services are crucial tools for ensuring accurate diagnoses and planning suitable treatment. Examples of CDSM imaging services are CT (Computed Tomography), PET (Positron Emission Tomography), Nuclear Medicine, and MRI (Magnetic Resonance Imaging). Any time any of these services are ordered, providers are required to consult the CDSM and receive a determination whether or not the order follows AUC guidelines.
All physicians and other providers who treat Medicare patients and any facility that furnishes those services in a physician’s office, hospital outpatient department, ambulatory services department, or independent diagnostic testing facility will be required to adhere to the regulation. The program is now in the educational and operational testing phase, so no payment consequences will result from not following the recommended workflow. Providers should take this time to familiarize themselves with the process, however, as any practitioner who treats Medicare Part B beneficiaries will be required to abide by this rule from January 1, 2021 on.
The CDSM is a tool within your certified EHR. (All CEHRT systems should be on the 2015 certified version.) This tool must be enabled to be incorporated into the workflow. Ideally, this consult should be done at time of ordering, so the test will not be denied later. Embedding the AUC requirement into your workflow will ensure you are following prescribed guidelines and avoiding any payment penalties.
CareOptimize is ready to help any practitioner with any questions about this new rule. Our value-based experts can assist with:
• Ensuring your workflow is adjusted to accommodate the AUC requirement

• Enabling the tool within your EHR

This update is provided by CareOptimize. We provide healthcare management consulting services and products, managed care solutions, value-based expertise, Nextgen EHR utilities, MIPS consulting, and more. CareOptimize has helped numerous healthcare organizations succeed for more than a decade. For more information, please call 855.937.8475.