Medicare Sunsets Beleaguered Appropriate Use Criteria Program
By Emma Freer

After longstanding opposition from the Texas Medical Association and others, the Centers for Medicare & Medicaid Services (CMS) finally nixed the appropriate use criteria (AUC) program for advanced diagnostic services as part of the 2024 Medicare physician fee schedule.  

In a Feb. 15 policy update, CMS urged physicians and other affected parties to inform their billing staff of the: 

  • Rescinding of AUC program regulations; 
  • Pausing of the AUC program for reevaluation; and 
  • Elimination of AUC consultation information on Medicare fee-for-service claims. 

TMA staff experts welcome the change, saying the troubled AUC program required physicians to jump through administratively burdensome, costly, and duplicative hoops.  

Congress established the AUC program in 2014, which – under threat of future payment penalties – required physicians ordering advanced imaging tests to use an electronic portal to consult Medicare’s criteria for whether a test met Medicare’s definition of “appropriate use.” 

As CMS struggled with the AUC program’s implementation, TMA and others in organized medicine repeatedly warned the federal agency about the significant challenges posed by the program, including in a September 2021 letter sent with 39 other medical societies to three lawmakers, who had requested a report on the program. 

“If ever fully implemented, the AUC program would apply to every clinician who orders or furnishes an advanced diagnostic imaging test ... and would be layered on top of other CMS quality programs that are intended to ... incentivize appropriate use of health care resources,” TMA and the other signatories wrote. “Especially at a time when physician practices and hospitals are experiencing staffing shortages, they should not be expected to make investments in activities that are administratively burdensome and costly when the consultation of AUC could be incentivized through existing CMS quality programs.”  

TMA and other medical societies also noted that the program became obsolete after Congress passed the Medicare Access and CHIP Reauthorization Act (MACRA) in 2015. MACRA established new Medicare payment and delivery models, including the Merit-Based Incentive Payment System and alternative payment models, which hold physicians responsible for health care resource use. 

For more information on recent Medicare changes, check out the Medicare 2024 Payment Update webinar CME, available in TMA’s Education Center. 

Last Updated On

March 14, 2024

Originally Published On

March 06, 2024

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Emma Freer

Associate Editor

(512) 370-1383

Emma Freer is a reporter for Texas Medicine. She previously worked in local news, covering city politics, economic development, and public health. A native Clevelander, she graduated from Columbia Journalism School and the University of St. Andrews.

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