No Penalties for Now in Medicare’s Appropriate Use Criteria Program

The Centers for Medicare & Medicaid Services (CMS) has said it would postpone indefinitely the payment penalty phase of its appropriate use criteria (AUC) program, which was expected to begin as soon as Jan. 1, 2023.

Under the 2022 Medicare physician fee schedule, the AUC program was set for full implementation on the later of Jan. 1, 2023, or the Jan. 1 following the end of the public health emergency (PHE) for COVID-19. However, CMS later posted that the payment penalty phase would not begin Jan. 1, 2023, “even if the PHE for COVID-19 ends in 2022. … CMS is unable to forecast when the payment penalty phase will begin.”

U.S. Health and Human Services Secretary Xavier Becerra on Oct. 13 renewed the PHE for COVID-19, now extending till Jan. 11, 2023.

When the AUC program is fully implemented, physicians ordering advanced diagnostic imaging services – CT and PET scans, nuclear medicine, and MRIs – will have to use an electronic portal, called a “qualified clinical decision support mechanism,” to consult Medicare’s criteria that evaluate whether a test meets Medicare’s definition of “appropriate use.” Medicare will deny claims from physicians who don’t document that system check. 

The Protecting Access to Medicare Act of 2014 established the AUC program, and voluntary participation ran from July 1, 2018, through 2019. Then came the education and operation testing period, originally expected to last Jan. 1 through Dec. 31, 2020. However, CMS extended the testing period, which now continues. 

Although Medicare will not deny claims during the education and testing period, CMS encourages physicians to use this opportunity to learn, test, and prepare for the AUC program by getting used to consulting the portal and remembering to document this action on claims – to be prepared when the payment penalty is finally implemented.

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Last Updated On

October 25, 2022

Originally Published On

October 25, 2022

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