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CMS imaging appropriate use criteria: What PCPs need to know

Clinicians will need to undergo extensive planning to comply with the Protecting Access to Medicare Act of 2014’s Appropriate Use Criteria Program and avoid penalties, according to a paper published in the Annals of Internal Medicine.

CMS’s program will require health care providers to consult approved clinical use criteria using clinical decision supports when ordering advanced imaging, including CTs and MRIs, for Medicare patients in outpatient and ED settings.

“Despite the program's rapidly approaching start date of 1 January 2020, many internal medicine providers and organizational leaders may be unaware of [Protecting Access to Medicare Act] requirements and consequences of noncompliance. Inattention threatens to disrupt practice, and therefore care, for millions of Medicare beneficiaries.” Keith D. Hentel, MD, MS, of the department of radiology at Weill Cornell Medicine, and colleagues wrote.

The program requires clinicians to implement appropriate use criteria created and published by national professional societies, known as provider-led entities, approved by CMS. Each provider-led entity may create appropriate use criteria for any or all of the eight priority clinical areas identified by CMS, which include common clinical presentations such as headache and low back pain.

Consultations with appropriate use criteria must be done through a clinical decision support mechanism. To comply with program requirements, each mechanism must use criteria from at least two provider-led entities to ensure all eight priority clinical areas are covered.

CMS will allow for clinical staff, not just physicians, to complete clinical decision support mechanism consultation to help reduce workflow disruptions.

Clinical decision supports can be implemented though a standalone portal or by integrating them with existing electronic health records. Hentel and colleagues recommended that physicians begin the lengthy process of evaluating, purchasing, and implementing a clinical decision support mechanism as soon as possible to prepare for the start of the program.

Physicians and practices that conduct and interpret advanced imaging will be denied payment for claims that do not have documentation of consultation with appropriate use criteria.

CMS will collect and analyze data from physicians who order advanced imaging after the start of the program to determine if they adhere to appropriate use criteria. Those identified as outliers will eventually require third-party preauthorization to order imaging for patients with Medicare.

Hentel and colleagues noted that although the intended benefit of the Appropriate Use Criteria Program was to decrease Medicare costs and improve quality of care through the reduction of unnecessary imaging, there is little evidence that the program will achieve the goal. They also noted that despite efforts made by CMS, the program may shift ordering providers’ time from patient interaction to administrative obligations.

“All physicians and organizations must understand program requirements and their options for complying,” Hentel and colleagues wrote. “Substantial resources and planning will be needed to comply with these regulations and to help avoid unintended negative consequences on workow and payments.” – by Erin Michael

Disclosures: Hentel reports no relevant financial disclosures. Please see study for all other authors’ relevant financial disclosures.