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 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
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
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 Appropriate Use Criteria for Stress Imaging
- Symptomatic patients with intermediate to high risk for CAD, uninterpretable ECG, or inability to exercise
- Symptomatic patients with prior post-revascularization (PCI or CABG) or in asymptomatic patients when revascularization was incomplete and additional revascularization is feasible
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Patients with other cardiovascular conditions
- Newly diagnosed heart failure (systolic or diastolic)
- Arrhythmia with sustained VT, ventricular fibrillation, exercise-induced VT or nonsustained VT, frequent PVCs
- Prior to initiation of anti-arrhythmia therapy in high global CAD risk patients
- Syncope and intermediate or high global CAD risk
-
Sequential testing (≤90 days) with abnormal prior test results and
- Abnormal rest ECG or intermediate-to-high CAD risk
- Abnormal prior exercise ECG test
- Obstructive CAD on prior CCTA or prior invasive coronary angiography
- Abnormal prior CCT calcium (Agatston Score >100)
-
Sequential testing (≤90 days) with borderline, equivocal, or discordant prior results and
- Prior exercise ECG test
- Prior CCTA
- Sequential testing (≤90 days) with coronary stenosis or anatomic abnormality of unclear significance found on cardiac CCTA or previous coronary angiography
-
Follow-up testing with new or worsening symptoms and
- Normal or abnormal exercise ECG
- Nonobstructive CAD on angiography or normal prior stress imaging study result
- Obstructive CAD on CCTA or invasive coronary angiography
- Abnormal CCT calcium score (Agatston score >100)
- Preoperative evaluation in patients with poor or unknown functional capacity prior to kidney or liver transplant, or vascular surgery with ≥1 clinical risk factor(s)
- Asymptomatic patients with high global CAD risk, interpretable ECG, and able to exercise
- Asymptomatic patients with intermediate or high global CAD risk, uninterpretable ECG, or inability to exercise
- Asymptomatic patients with prior left main coronary stent
- Asymptomatic patients ≥2 years after PCI
- Asymptomatic patients ≥5 years after CABG
- Patients with other cardiovascular conditions
- Arrhythmia with infrequent PVCs or new-onset atrial fibrillation
- Syncope with low global CAD risk
- Follow-up testing
- Within 90 days of abnormal or uncertain stress imaging study result
- Asymptomatic or stable symptoms with last study ≥2 years ago or with abnormal calcium score (Agatston score ≥100)
- New or worsening symptoms and abnormal prior stress imaging study result
- Asymptomatic or stable symptoms with intermediate to high global CAD risk and last study ≥2 years ago
- Preoperative evaluation prior to intermediate-risk noncardiac surgery in patients with poor or unknown functional capacity and ≥1 clinical risk factor(s)
- Evaluation prior to cardiac rehabilitation for patients with heart failure
- Symptomatic patients with low risk of CAD, interpretable ECG, and ability to exercise
- Asymptomatic patients with low global CHD risk
- Asymptomatic patients with intermediate global CHD risk, interpretable ECG, and ability to exercise
- Asymptomatic patients <2 years after PCI
- Asymptomatic patients <5 years after CABG
- Follow-up testing for asymptomatic patients or patients with stable symptoms with last test <2 years ago or low coronary calcium score (Agatston score <100)
- Preoperative evaluation before noncardiac surgery
- Prior to low-risk surgery in patients with poor or unknown functional capacity and ≥1 clinical risk factor
- In asymptomatic patients with normal prior testing or revascularization <1 year ago
- In patients with moderate to good functional capacity or no clinical risk factors
- Evaluation prior to the initiation of cardiac rehabilitation
- In patients able to exercise post-revascularization (PCI or CABG), except in patients with heart failure
- In patients without prior revascularization
ACCF = American College of Cardiology Foundation; CABG = coronary artery bypass graft; CCT = coronary computed tomography; CCTA = coronary computed tomography angiography; CHD = coronary heart disease; PCI = percutaneous coronary intervention; PVC = premature ventricular contraction; VT = ventricular tachycardia.
Multimodality AUC Resources and Information
A resource with information about the Multimodality AUC and the Centers for Medicare & Medicaid Services (CMS) federal mandate, plus a downloadable AUC tool to help guide imaging decisions.
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 AUC program is being implemented in a stepwise approach to help healthcare providers prepare. The Educational and Operations Testing Period for implementation of the AUC began January 1, 2020. During this phase, the CMS expects6,a:
- Ordering professionals to consult a qualified Clinical Decision Support Mechanism (CDSM)7 and communicate the results to the nuclear imaging provider
- Furnishing providers to report 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.
AUC Stepwise Implementation Timelinea
Phase 1. Educational and Operations Testing Period (began January 1, 2020)6
- 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 (for timing, go to the AUC Program page of the CMS website)8
- Furnishing providers must include information regarding the ordering professional's consultation of a qualified CDSM, or an exception to consultation, for the claim to be paid by Medicare
- Outlier ordering patterns may result in prior authorization in future years
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 to review the appropriateness of 7 different noninvasive cardiac testing modalities (based on the AUC) for the detection and risk assessment of 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(1):7-13. 5. Lane E. 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 03-04-2022. 6. Centers for Medicare & Medicaid Services. Appropriate use criteria (AUC) for advanced diagnostic imaging – educational and operations testing period – claims processing requirements (12-06-2019). https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11268.pdf. Accessed 03-04-2022. 7. Centers for Medicare & Medicaid Services. Clinical decision support mechanisms (12-01-2021). https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/CDSM.html. Accessed 03-04-2022. 8. Centers for Medicare & Medicaid Services. Appropriate use criteria program (07-07-2022). https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/. Accessed 08-27-2022.
