Complex Diagnostic Imaging and the CMS Imaging AUC Program

Across varying backgrounds and fields of study, there seems to be one thing that doctors agree on: Imaging has always been a challenge.

To kick off “Session 5: Screening and Testing in the Clinical Pathways” at the 2022 Oncology Clinical Pathways Congress, Elliot K. Fishman, MD, FACR, Professor of Radiology, Oncology, Surgery and Urology, Johns Hopkins Hospital, presented “Pathways to Guide the Appropriate Use of Complex Diagnostic Imaging – The CMS Imaging AUC Program” to discuss these challenges.

Because imaging technology is constantly evolving, decisions on the best imaging approach in clinical settings vary. Factors such as multiple modalities change based on availability and experience, scan protocols’ need for specificity, and how most physicians are unsure of study orders.

“Every clinician, every radiologist knows the challenge with imaging,” Dr Fishman said. “Imaging is constantly changing, there are constant developments in CT, MRI, PET, they constantly evolve. So what is the best imaging modality for any study? It’s always in flux. For the radiologist it’s a challenge. For the non-radiologist, it’s particularly difficult.”

The Protecting Access to Medicare Act (PAMA) of 2014, Section 218(b), established the Appropriate Use Criteria (AUC) program to increase the rate of appropriate advanced diagnostic imaging services (CT, MRI, PET, etc) provided to Medicare beneficiaries.

Through the AUC program, practitioners can order advanced diagnostic imaging services for a Medicare beneficiary and will be required to consult a qualified Clinical Decision Support Mechanism, an electronic portal through which AUC is accessed. This portal determines whether or not the order placed adheres to the AUC program or if it was not applicable.

A consultation must take place at the time of the order for imaging services. Practitioners whose ordering patterns are considered outliers will be subject to prior authorization, with further information on that process to come.

“The program decided to have provider-led entities (PLEs),” Dr Fishman said. “If you follow their criteria, your studies will be approved. You need to be very specific, and it has to be multidisciplinary. As of June 2022, there were a number of qualified PLEs. The challenge was in how can you use them in a way that makes it simple for the referring physician and at the end of the day, be built into medical records.”

The AUC program impacts all physicians and practitioners who order advanced diagnostic imaging services, as well as physicians, practitioners, and facilities that furnish advanced diagnostic imaging services in an office, hospital outpatient department, an ambulatory surgical center, or an independent diagnostic testing facility. Those whose claims are paid under the physician fee schedule, hospital outpatient prospective payment system, or ambulatory surgical center payment system will also be impacted.

The use of guidelines for imaging is here, concluded Dr Fishman. Groups that provide expertise in imaging are key to the AUC program’s success.

“The goal is really to have one standard,” he said. “The reality is, most patients are seen at non-academic centers and the key is to make those non-academic centers perform as well as the academic centers with the goal providing perfect patient care for everybody.

“Guidelines for imaging are here to stay. It is still somewhat of a challenge, there’s still going to be variations, I think we all agree we need to set minimums. Patient care improves by choosing the right exam for the right reason, and I think people’s comfort in imaging improves when they know it’s going to be the right study. I think this works perfectly—optimizing patient care and minimizing costs.”