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Appropriate Use Criteria

Appropriate Use Criteria

Appropriate Utilization of Cardiac Imaging

What the AUC Mean for Your Clinical Practice

ASNC strongly advocates imaging tailored to the individual patient. Although standardized testing may help simplify clinical decision-making, it may lead to inappropriate tests and suboptimal results. Individualizing the testing experience may help patients feel more comfortable during their test.1

The Appropriate Use Criteria (AUC) provide recommendations for performing the right test on the right patient at the right time. The ultimate objective of the AUC is to improve patient care and health outcomes in a cost-effective manner.2

Both the referring and imaging providers should be sufficiently knowledgeable about the benefits and risks of the requested imaging study and discuss this in sufficient detail with the patient to optimally guide decision-making.3

In a meta-analysis of 7 studies that examined quality improvement initiatives for cardiac testing, interventions utilizing physician audit and feedback were strongly associated with a reduction in inappropriate testing and, therefore, the authors concluded that this can help improve the clinical value of cardiac testing.4

Find and share additional information on the AUC on CardiacTesting.com, an online resource designed to support referring and ordering providers. Astellas also offers educational speaker programs to help spread awareness and knowledge about the AUC and cardiac testing.

Helping to Reduce Inappropriate Ordering

Reducing inappropriate imaging orders helps increase the quality of care. One way in which imaging departments may help avoid inappropriate tests is by systematically checking orders. Detecting and correcting an inappropriate imaging order before the test is performed can help improve the overall value of care delivered.5

ACCF Guidelines: Appropriate Use Criteria for Advanced Imaging

ACCF = American College of Cardiology Foundation; CABG = coronary artery bypass graft; CCTA = coronary computed tomography angiography; CHD = coronary heart disease; ECG = electrocardiogram; PCI = percutaneous coronary intervention; PVC = premature ventricular contraction; VT = ventricular tachycardia.

The Hierarchy of Indications for Ordering Tests

To help referring providers assess appropriateness for further testing, The Hierarchy of Indications for Ordering Tests can inform ordering decisions for patients who present with multiple clinical indications.

Referring providers can also visit Refer Wisely for assistance in decision-making. These resources can aid communication between team members and facilitate appropriate testing referrals, which may contribute to efficiency in the nuclear lab.

Staying Informed About the CMS Federal Mandate

The Educational and Operations Testing Period for implementation of the AUC began January 1, 2020. During this phase, the Centers for Medicare & Medicaid Services (CMS) expects6,a:

  • Ordering professionals to begin consulting a qualified Clinical Decision Support Mechanism (CDSM)7 and communicating the results to the nuclear imaging provider
  • Furnishing providers to begin reporting the AUC consultation information on Medicare claim forms, including6:
    • The appropriate Healthcare Common Procedure Coding System (HCPCS) modifier to describe the level of adherence to the AUC or an exception
    • G-code identifying the CDSM that was used by the referring provider

aDetails regarding the Medicare AUC program, including the implementation date, are subject to change without notice based on updates issued by CMS.

The AUC program is being implemented in a stepwise approach to help healthcare providers prepare. Claims will not be denied for misreporting AUC information or failing to include AUC-related information on claim forms during the test period, although inclusion is encouraged.6

After full AUC implementation, information regarding the referring provider’s consultation of the AUC with a CDSM, or an exception to consultation, must be included on the imaging provider’s Medicare claim forms. Providers who do not routinely consult and report the AUC may be identified as outliers and could be subject to prior authorization.6

To read about the latest information on the AUC program implementation, go to the AUC Program page of the CMS website.

For more information about qualified CDSMs, visit the CDSM
section of the CMS website.
AUC Stepwise Implementation Timeline6,a

Phase 1. Educational and Operations Testing Period: January 1, 2020 – December 31, 2020

  • Ordering professionals must begin consulting the AUC and must report utilization to the furnishing provider
  • Claims will not be denied for failing to include AUC-related information (eg, CDSM G-code, HCPCS modifiers) on claim forms, but inclusion is encouraged

Phase 2. Full implementation: currently set for January 1, 2021

  • Furnishing providers must include information regarding the ordering professional's consultation of a qualified CDSM for the claim to be paid by Medicare
  • Outlier ordering patterns may result in prior authorization in future years

In addition, the Merit-based Incentive Payment System (MIPS) recognizes utilization of the AUC as an "improvement activity," which counts toward the overall performance score under the MIPS program.8

aDetails regarding the CMS AUC program, including the implementation date, are subject to change without notice based on updates issued by CMS.

The Multimodality AUC App

This useful app allows providers in the nuclear lab to review the appropriateness of 7 different noninvasive cardiac testing modalities (based on the AUC) for the detection and risk assessment of stable ischemic heart disease (SIHD).

The Multimodality AUC App is not intended to diagnose, treat, or prevent any disease or condition. It is also not a qualified CDSM. Thus, the Multimodality AUC App must not be used to try and comply with the CMS AUC program requirements. The Multimodality AUC App is for informational purposes only.

References+

1. Dorbala S, Ananthasubramaniam K, Armstrong IS, et al. Single Photon Emission Computed Tomography (SPECT) myocardial perfusion imaging guidelines: instrumentation, acquisition, processing, and interpretation. J Nucl Cardiol 2018;25(5):1784-846. 2. Wolk MJ, Bailey SR, Doherty JU, et al. ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 multimodality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease. J Am Coll Cardiol 2014;63(4):380-406. 3. Einstein AJ, Berman DS, Min JK, et al. Patient-centered imaging: shared decision making for cardiac imaging procedures with exposure to ionizing radiation. J Am Coll Cardiol 2014;63(15):1480-9. 4. Chaudhuri D, Montgomery A, Gulenchyn K, Mitchell M, Joseph P. Effectiveness of quality improvement interventions at reducing inappropriate cardiac imaging. A systemic review and meta-analysis. Circ Cardiovasc Qual Outcomes 2016;9:7-13. 5. Halim L. Advancing appropriate use of imaging (02-05-2019). https://www.advisory.com/research/imaging-performance-partnership/research-report/2019/advancing-appropriate-use-of-imaging. Accessed 05-06-2019. 6. Centers for Medicare & Medicaid Services. Appropriate use criteria (AUC) for advanced diagnostic imaging – educational and operations testing period – claims processing requirements. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11268.pdf. Accessed 09-18-2019. 7. Centers for Medicare & Medicaid Services. Clinical decision support mechanisms (07-01-2019). https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/CDSM.html. Accessed 07-02-2019. 8. Centers for Medicare & Medicaid Services. 2018 MIPS advancing care information performance category fact sheet. https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/2018-Advancing-Care-information-Fact-Sheet.pdf. Accessed 05-08-2019.