AUC Program, Another Piece to the Unfolding Healthcare Consumer Landscape

The healthcare industry is almost four months into the testing period for the Appropriate Use Criteria (AUC) Program.

In less than nine months, consultation of an AUC Clinical Decision Support mechanism (CDSM) and reporting of consultation on the billing claim will become a requirement. With the recent finalization of the Price Transparency rule and the 21st Century Cures Act, it is clear that AUC is one more stride towards standardized care as a way to improve the healthcare experience.

As part of the Protecting Access to Medicare Act of 2014, AUC requires healthcare professionals in specific care settings to consult a CDSM when ordering an advanced diagnostic imaging test.

Advanced diagnostic imaging services that fall under AUC may include:

• Computed tomography (CT)
• Positron emission tomography (PET)
• Nuclear medicine
• Magnetic resonance

The AUC Program will apply to the following care settings:

• Physician offices
• Hospital outpatient departments
• Emergency departments
• Ambulatory surgical centers
• Independent diagnostic testing facilities

The purpose of the AUC Program is to prevent patients from being unnecessarily exposed to high levels of radiation while also reducing the unqualified ordering of expensive digital imaging services. According to the American Medical Association, the program’s main focus is to ensure the most relevant services are working to achieve the best health outcomes. In that respect, the AUC Program has both financial and care quality benefits for healthcare consumers.

How AUC Program Will Work – The Basics

Effective January 1, 2021 adherence to the AUC Program will be mandatory. At that time:

• Ordering physicians will need to consult a CMS qualified clinical decision support mechanism.
• Ideally, a CDSM query will be automated into a provider’s EHR workflow.
• If consulted, the CDSM will return HCPCS (Healthcare Common Procedure Coding System) modifiers that will let the performing entity (e.g. hospital or imaging lab) know if AUC was met.
• Appended to the order will also be a G code designating which qualified CDSM was referenced.
• If the order meets AUC billing requirements, reimbursements will go through as normal.
• If the order does not meet AUC billing requirements or no AUC modifier is reported, the imaging service may not qualify for reimbursement.

As the program matures, ordering providers who do not consult a CDSM may be flagged as outliers. CMS has noted that future limitations may also go into effect for outlying providers, such as requiring prior authorization for any advanced diagnostic imaging services.

AUC Challenges and How to Best Prepare

While AUC requirements are directed at ordering providers, it is the performing entity that may be impacted financially. Hospitals and providers may also find additional challenges when receiving orders from physicians not on their staff.

If an order comes from a physician’s office with no G code or HCPCS modifiers, it will be the performing entity’s responsibility to track that information down. Inquiries relating to AUC and CDSM may also create workflow disruptions for the performing entity.

When AUC is not adhered to it may also result in several revenue cycle management (RCM) roadblocks for both ordering and performing entities. Coding errors that lead to line item or complete denials are just one example of potential AUC billing issues. Any billing errors that result from circumventing AUC may also have a rippling effect on the healthcare consumers’ experience.

“There is a real need for ordering physicians and providers to clearly communicate throughout this process,” says Lisa Scott, MEDHOST Regulatory Analyst Financial Products. “A big part of that communication will come down to ordering professionals making sure all their systems are talking to each other – EHR, CDSM, and other clinical tools.”

AUC Is Part of a Bigger Movement

From a holistic perspective, MEDHOST regulatory specialists believe the AUC Program is a smaller piece of a larger effort to leverage healthcare IT in ways that provide safer and appropriate care. The AUC Program hopes to achieve these care improvements through the use of Clinical Decision Support. By fully utilizing CDSMs, hospitals can better control the cost of healthcare while increasing the quality of care delivered, for instance, reducing exposure to radiation.

Hospitals have less than a year to prepare and test for the AUC Program. For those looking for ways to reduce regulatory burdens, build reliable automation into orders, or just need some direction, MEDHOST is ready to help.

To learn more about MEDHOST clinical decision support solutions email inquiries@medhost.com or call 1.800.383.6278.