Centers for Medicare and Medicaid Updates

CMS Pauses Appropriate Use Criteria Program

CMS announced it will no longer accept report coding on claims as of December 31, 2024.

The Centers for Medicare and Medicaid Services (CMS) published the following:

As announced in the CY 2024 Physician Fee Schedule (PFS) Final Rule, effective January 1, 2024, CMS has paused efforts to implement the AUC program for reevaluation and rescinded the AUC regulations at 42 CFR 414.94. CMS has not specified a timeframe within which implementation efforts will recommence. See pages 79256-79265 of the final rule.

Effective January 1, 2024, providers and suppliers should no longer include AUC consultation information on Medicare FFS claims. However, claims containing AUC related codes with dates of service in 2023 and 2024 will continue to process through December 31, 2024.

Additionally, CMS will no longer qualify PLEs or CDSMs and has removed this information from the AUC website. The claims processing instructions and guidance for the previous voluntary period and educational and operations testing period will be removed.

For more information, see the following guidance documents issued in February 2024:

– One Time Notification – Appropriate Use Criteria for Advanced Diagnostic Imaging Policy Update in the Calendar Year 2024 Physician Fee Schedule Final Rule (CR 13458, Transmittal 12508, issued 2024-02-15 (PDF))

– MLN Matters Article – Appropriate Use Criteria for Advanced Diagnostic Imaging: CY 2024 Update (MM13485, Issued 2024-02-21 (PDF))

CMS.GOV

What this means for MEDENT practices:

Although CMS has paused the AUC program, MEDENT clients who order exams can still use the NDSC-CareSelect interface for AUC checking. Offices may want to continue using such tools for quality ordering and other reasons.

If you only order PAMA exams:

You may continue to do so, as long as the performing facilities have no objection to the AUC information being included on the exam requisitions.

If you only order order PAMA exams because it was to become a required program for CMS/Medicare Part B and Railroad and you have no other use for it, you may ask MEDENT to turn off the prompting and, if desired, the interface itself. To do so, please submit an online support request and indicate whether you would like the prompting and/or interface turned off.

If you only order PAMA exams for reasons other than to participate in the anticipated CMS AUC check reporting program, you may continue using the features as they are set up. If you want to remove the CMS/Medicare Part B and Railroad insurances from your setup and need assistance, please submit an online support request.

If you only perform PAMA exams:

You will need, at a minimum, to edit the Diagnostic Imaging AUC Setup screen by removing those insurances that represent Medicare Part B and Railroad insurances, so they will no longer prompt for the reporting code and modifier for each PAMA exam included in the patient’s superbill/charge entry. Please submit an online support request if you need assistance.

If you order AND perform PAMA exams:

You will need, at a minimum, to edit the Diagnostic Imaging AUC Setup screen by removing those insurances that represent Medicare Part B and Railroad insurances, so they will no longer prompt for the reporting code and modifer for each PAMA exam included in the patient’s superbill/charge entry. Please submit an online support request if you need assistance.