CMS Releases Fact Sheet/Practical Guide for Appropriate Use Criteria

Posted by


By Adrienne Dresevic, Esq. of The Health Law Partners, P.C.

 This article updates a previous LINK article “The Final 2019 MPFS: What Radiology Providers Need to Know” published on December 17, 2018.

As previously reported, on November 1, 2018, the Centers for Medicare and Medicaid Services (CMS) released the 2019 Medicare Physician Fee Schedule Final Rule (2019 MPFS Final Rule), which requires providers of advanced diagnostic imaging services to take certain steps when a referral for advanced medical imaging is made. Specifically, referring providers will need to consult Appropriate Use Criteria (AUC) through a qualified Clinical Decision Support Mechanism (CDSM) when ordering advanced medical imaging services for Medicare beneficiaries. Ordering clinicians must also communicate this information to the provider or facility furnishing the advanced diagnostic imaging services (e.g. radiology services).

In December 2018, CMS’ Medicare Learning Network® (MLN) released an Appropriate Use Criteria for Advanced Diagnostic Imaging fact sheet/practical guide (Fact Sheet) to assist providers in meeting CMS’ federal mandate for 2020.

Appropriate Use Criteria Requirements for Advanced Diagnostic Imaging Services

By way of background, CMS is tasked with establishing a program to promote the use of AUC for advanced diagnostic imaging services. AUC is an advanced form of clinical guidelines to assist clinicians in determining what imaging should be performed based upon certain criteria, such as the individual patient, scientific evidence, the risk and benefit of such testing and available healthcare resources.

In the 2016 MPFS Final Rule, CMS addressed the initial component of the new Medicare AUC program, establishing evidence-based process and transparency requirements for the development of AUC. In the 2017 MPFS Final Rule, CMS addressed requirements and the process for specification of qualified CDSMs and other related policies. In the 2018 MPFS Final Rule, CMS addressed changes in the relative value of services, and changes to the applicable statute. In the 2019 Final Rule, CMS addressed the requirements for consulting and reporting under the Medicare AUC program.

CMS’s MLN Fact Sheet/Practical Guide for AUC Reporting Requirements

CMS released the Fact Sheet to serve as a guide for providers ordering or furnishing advanced diagnostic imaging service to prepare for the AUC consultation and reporting requirements beginning January 1, 2020. The Fact Sheet acts as a practical guide and provides an overview of AUC consultation requirements, AUC reporting requirements, implementation dates, and potential exceptions to the AUC reporting requirements.

AUC Reporting Requirements for Calendar Year 2020

The Fact Sheet notes that beginning in 2020, a provider that orders Medicare B advanced diagnostic imaging services will be required to consult AUC through a qualified CDSM. Further, any claims for advanced diagnostic imaging services from a referring provider or a provider that furnishes (performs) the advanced diagnostic imaging services to be paid through any of the following payment systems will be required to perform AUC consultation: Physician Fee Schedule, Outpatient Prospective Payment System, or the Ambulatory Surgical Center Payment System.

Required information to be reported by the referring provider includes:

  • The ordering professional’s NPI;
  • Which CDSM was utilized to provide the consultation; and
  • Whether the service ordered would or would not adhere to the consulted AUC or whether the consulted AUC was not applicable to the service ordered.

CMS also notes that the referring provider may delegate the AUC consultation to clinical staff under his/her direction if the provider does not personally perform the consultation. Further, the referring provider must communicate this information to the furnishing provider. Furnishing providers will be required to report the AUC consultation information when making Medicare claims.

Prior to January 1, 2020, providers may voluntarily participate in the AUC program. As detailed by the Fact Sheet, if a provider chooses to participate in the AUC program, they are to append a new HCPCS modifier “QQ” to the CPT code on the claim. This modifier signifies the provider completed the appropriate consultation.

Currently, CMS has not issued guidance regarding what the claims-based reporting requirements will be in 2020, when the AUC program is no longer voluntary.

Exceptions to AUC Reporting Requirements

CMS may make the following exceptions to the AUC reporting requirements beginning in 2020:

  • Emergency services, when provided to patients with certain emergency medical conditions (as defined in Section 1867(e)(1) of the Social Security Act)
  • Inpatients and for which Medicare Part A payment is made, and
  • Ordering professionals, when experiencing a hardship. The hardships of an ordering professional include: insufficient internet access, electronic health record (EHR) or CDSM vendor issues, and extreme/uncontrollable circumstances.


The Fact Sheet published by CMS’ MLN acts as a practical guide and provides two tables with links to helpful resources for providers. The tables include links to sections of the AUC Program, an MLN article regarding claims processing requirements for the AUC Program, a list of qualified CDSMs, and a list of Priority Clinical Areas. The Fact Sheet also directs providers to submit any questions regarding the AUC program to Radiology providers and suppliers would be well advised to download the Fact Sheet in preparation for the AUC program requirements beginning in 2020.

For more information on issues relating to this article, please contact Adrienne Dresevic, Esq. at (248) 996-8510 or by email at

Adrienne Dresevic, Esq, is a founding shareholder of The Health Law Partners, PC, a nationally recognized healthcare law firm with offices in Michigan and New York. Practicing in all areas of healthcare law, she devotes a substantial portion of her practice to providing clients with counsel and analysis regarding compliance, Stark Law, Anti-Kickback Statute, and compliance related issues. Ms. Dresevic is a member of the American Bar Association Health Law Section’s Council, which serves as the voice of the national health law bar within the ABA. Ms. Dresevic is the Section’s Budget Officer.  She also served as the ABA Health Law Section’s Co-Chair of the Physicians Legal Issues Conference Committee, Vice Chair of the Programs Committee (Executive Leadership), and Vice Chair of the Sponsorship Committee. She is licensed to practice law in Michigan and New York, and can be contacted at

The author is a member of The Health Law Partners, PC and may be reached at (248) 996-8510 or (212) 734-0128, or at



Post a Comment

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s