Appropriate Use Criteria

WHAT

Protecting Access to Medicare Act (PAMA) requires referring providers to consult appropriate use criteria (AUC) prior to ordering advanced diagnostic imaging services (ADIS) including CT, MR, Nuclear Medicine and PET. It is important to note that the law does not mandate ordering providers to strictly adhere to the AUC, just consult AUC. Unlike prior authorization, there is no “hard stop” to the ordering process. We are highlighting this requirement to ensure the implementation process goes smoothly and your patients continue to receive the best quality care

WHY

Appropriate Use Criteria is an alternative to CMS requiring pre-authorization for all advanced imaging — which could pave the way for other payers to eliminate this burdensome step. The result? Easy access to AUC can help keep evidence-based decision making between physicians and patients, as unlike “hard stop” prior authorization, AUC consultation allows physicians to choose the best test for patients based on their individual circumstances.

Imaging CDS technology can help identify opportunities for quality improvement initiatives and spark collaboration between radiologists and referring providers around improvements in value-based imaging.

HOW

We are working to help referring providers access the tools they need to provide the documentation needed for this mandate. Providers will have access to two to three free options and will need to work with their staff to decide which tool is best for their practice. 

Royal MD is a product offered to our small to medium-sized offices through our RIS/EMR system. The product offers patient tracking, report and image viewing, electronic ordering, and the CDS/AUC (through Care Select Advance) mechanism. 

Care Select (a qCDSM) offers a free version of the mechanism. Any provider can use this tool to create and provide the information to be placed on an order. 

Lastly, most EMR/EHR will have a qCDSM available as a build in. Contact your EMR/EHR vendor for more information.