CMSPROPOSES TEMPORARY HALTTO APPROPRIATEUSECRITERIA Proposing Temporary Halt

In the 2024 Medicare Physician Fee Schedule (MPFS) Proposed Rule released on July 13, 2023, the Centers for Medicare and Medicaid Services (CMS) proposed pausing the implementation of the Protecting Access to Medicare Act (PAMA) imaging Appropriate Use Criteria (AUC) program

The real-time claims processing aspect of the program has been a challenge, leading to the need for reevaluation:

?? We have exhausted all reasonable options for fully operationalizing the AUCprogram consistent with the statutory provisions,?CMSstates in the proposed rule The proposal suggests additional time is required to reassess the program, aiming to prevent any unjustified denial of imaging claims

The PAMA imaging AUCprogram, signed into law in 2014, was designed to reduce unnecessary imaging by requiring providers to consulta Clinical Decision Support Mechanism (CDSM)when ordering advanced diagnostic imaging tests for Medicare Part B patients. The impacted modalities included CT, MR, PETand nuclear medicine procedures.

The program was created as a substitute for prior authorization to reduce unnecessary imaging. If fully implemented, imaging services lacking the required AUCconsultation information on applicable claims would be ineligible for payment Since January 1, 2020, the program has been in an "educational and operations testing period" without payment penalties. The proposal to temporarily halt the program also involves pausing this ongoing testing period.

Despite the challenges, CMSrecognizes the value of AUCin improving utilization patterns for Medicare beneficiaries and potential cost savings. The American College of Radiology (ACR) is working with Congress to address issues and modernize the program while encouraging the voluntary use of CDSM tools

For additional information about the AUCprogram, please see the following PARA Papers located in the Advisor tab of the PARA Data Editor:

Medicare?s Appropriate Use Criteria Program

Appropriate Use Compliance Deadline Delayed