Another Delay for Appropriate Use Penalties Is Proposed; Hospitals Still Find Glitches

Partly because of the COVID-19 pandemic, CMS is again planning to delay pulling the trigger on the penalty phase of the appropriate use criteria (AUC) requirement for advanced diagnostic imaging, which was scheduled to take effect in January 2022, according to the 2022 proposed Medicare Physician Fee Schedule (MPFS) rule.[1] If the delay is finalized, penalties for not getting an AUC consultation will kick in Jan. 1, 2023, or at the end of the year in which the public health emergency is over (whichever is later), and eventually outlier physicians will be put on prior authorization. The extra time could help hospitals and physicians work through glitches as they adapt to their clinical decision support mechanism (CDSM), an electronic tool that indicates whether the imaging services are appropriate.

“We have been testing and using a CDSM tool for a while,” said Patrick Kennedy, executive director of hospital compliance at UNC Health in North Carolina. “We are seeing the same potential risk on the hospital and professional side.” From a compliance standpoint, it’s helpful because “this is not just a hospital thing. The requirements are the same on both sides of the fence.” But there’s a disconnect between the ordering physician, who must do the AUC consultation, and the radiologists and hospitals that will lose payment for advanced imaging (e.g., CT scans, MRIs and PET scans) if everything doesn’t fall into place. That includes ordering physicians using the CDSM and radiologists and hospitals reporting modifiers and condition codes on their claims.

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