Appropriate Use Criteria (AUC) is a lesser-known government law that will affect everyone who orders advanced imaging procedures—a staple of orthopaedic practices. AUC is part of the Medicare Physician Fee Schedule regulations.
The law will impact the ordering, performing, and payment for advanced imaging procedures beginning January 1, 2020. The initial year (2020) will be an educational and testing year that will not affect payment.
Included in the advanced imaging procedure category are MRI, CT, PET, and nuclear studies. While certain specialties may not order many PET or nuclear studies, MRI and CT are staples in the diagnostic pathway and help determine care.
How does the law work?
The government is mandating that before any advanced imaging procedure is ordered, the ordering provider must consult an approved Clinical Decision Support Mechanism (CDSM). The CDSM will consider multiple factors on the patient and provide a recommendation as to whether or not the ordered procedure is appropriate or whether an alternative would be better.
At this point, providers have the choice to continue with the original order or to follow the CDSM recommendations. Information provided in the CDSM recommendation must be provided to the furnishing provider (imaging facility). The imaging facility must then include this information on the claim to the payer, and data on the choices made by the ordering provider will be stored in the CDSM for future auditing purposes.
Those who do their own in-house imaging will be impacted on the ordering and furnishing side. Your EHR, Radiology Information System (RIS), and claims management system will all need to be updated with new software to manage this.
We encourage you to speak with your EHR vendor to make the process of remaining compliant and meeting the requirements as seamless and minimally invasive as possible.
Prior to becoming the Director of Product Management at SRS, Barbara was with GE Healthcare (now GE Digital), where she held the positions of Senior Product Marketing Manager for Centricity imaging products, Product Marketing Manager and Customer Collaboration Leader for what is now Caradigm, and Upstream Marketing Manager for Centricity Laboratory. Barbara also worked at the University of Arizona Medical Center, where she managed a team that was responsible for implementing and maintaining 27 departmental IT solutions, the ambulatory EMR and the patient safety initiatives.
Originally from New Jersey, Barbara now lives with her husband in Tucson, AZ. She is a graduate of the West Virginia University College of Medicine and is a registered Medical Technologist. When not at work, she loves traveling, taking photographs, watching football and spending time with her two Brittanys.
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