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Significant changes are coming to Medicare concerning advanced imaging procedures and reimbursement. The Protecting Access to Medicare Act (PAMA) of 2014 established the Appropriate User Criteria (AUC) program, which will change the way providers order imaging such as CT scans, MRIs, PET scans, and nuclear medicine. In order to control costs and assist with quality care, CMS will be exerting tighter control over what procedures are considered medically necessary for patient care. If a medical provider fails to follow the criteria, CMS may deny a patient's claim. Prepare for AUC impacts by configuring NextGen EHR before the January 1, 2021 deadline.

For years, segments of the medical community and government agencies have been sounding the alarm about unnecessary imaging. Not every backache, fall, or headache requires an MRI or CT scan. Most providers are careful about ordering these tests, but some abuse the process, leading to excessive claims. CMS believes that the AUC program will assist in limiting unnecessary expenditures. 

The Appropriate Use Criteria Program, or AUC, does not officially begin until January 1, 2021. CMS is urging medical providers to assess the system this year while in the Education and Operations Testing Period to understand the process better and avoid penalties. The hope is that this testing period will prevent frustrating claim denials in the future.

The impact of AUC will be far-reaching and has the potential to affect how providers treat their Medicare patients. It will undoubtedly discourage unnecessary imaging, but it may also negatively impact patient care if not handled well. 

AUC Requirements for NextGen EHR Physicians

Under the AUC, covered providers will be required to consult a CDSM, or clinical decision support mechanism, whenever they order one of these advanced imaging techniques. A CDSM is an electronic portal that will determine if the procedure follows AUC requirements for patient treatment. If the CDSM renders a negative verdict, the physician is still free to order the test. However, there may be consequences with being reimbursed. NextGen EHR users will have a CDSM within NextGen EHR they must use to meet the program requirements.

Providers must consult the CDSM when they order the imaging to stay compliant with AUC. Also, providers who demonstrate "outlier" practices will eventually have to receive a formal preauthorization before an imaging procedure is covered. Before every advanced imaging procedure, getting a preauthorization would be time-consuming and take away time from other staff duties. That's why mastering the system now is so essential.

Affected Providers

The AUC applies to most providers that accept Medicare:

  • All providers who order advanced imaging tests  

  • Physicians, practitioners, and facilities that provide these services in either a:

    • Physician's office

    • Hospital outpatient department (including the emergency department)

    • Ambulatory surgical center 

    • Independent diagnostic testing facility (IDTF)

AUC Impact

The AUC comes with a "soft" open since the testing period comes without any penalty. Once the program goes fully into effect, the consequences will begin. Physicians who fail to order with a CDSM may not bill for the exam. Those who repeatedly ignore the CDSM consultation end up on the preauthorization list. The AUC will also impact providers in the following ways:

  • Only the ordering physician can determine if the test is an emergency. Neither the rendering physician nor the reading radiologist will be able to label a situation as such.

  • Reading radiologists will receive payment denials if they interpret results without a CDSM consult.

  • The ordering provider must enter the CDSM notes on the imaging order. 

  • Starting January 1, 2021, AUC consultation details must be added to diagnostic service claims to avoid rejections or payment reductions.

Clinical Areas for Baseline

The CMS has defined the following eight priority areas for AUC consultations:

  • Coronary artery disease

  • Headache - traumatic or non-traumatic

  • Suspected pulmonary embolism

  • Hip pain

  • Low back pain

  • Shoulder pain

  • Lung cancer

  • Cervical or neck pain

While these are the priority areas for imaging, once the AUC goes into full effect in January of 2021, AUC consultation will be required for all advanced imaging orders.

AUC Implementation with NextGen EHR 

NextGen has joined with the National Decision Support Company (NDSC) to prepare for the AUC implementation, which has integrated its CDSM solution into NextGen EHR. As a result, NextGen templates and the Orders Module will automatically display the NDSC score wizard with AUC feedback once the software configuration is complete. Configuration for utilizing AUC within NextGen EHR includes:

  • Map the NextGen Compendium to appropriate CPT codes to the test ordered by your providers

    • Mapping is already finished in NextGen EHR 5.9.1 versions and higher

  • Modify Practice Settings in NextGen File Maintenance

  • Enable AUC to run in the Practice Configuration EHR Template to ensure a seamless workflow within the templates

  • Adjust payer set up so that AUC data is required for all pertinent orders and claims data

Also, NextGen Healthcare is continuously improving on NextGen EHR AUC functionality with patches and version releases. If your providers are going to be heavily using the new AUC functionality, it may be worth exploring a NextGen upgrade to a newer release to enhance AUC functionality. For example, AUC functionality does not exist in the Cardiology Procedure until NextGen 5.9.3. The newer NextGen EHR AUC features & functionality make AUC compliance much more accessible and could prevent your physicians from being labeled "outliers" and forced into the preauthorization queue.

The TempDev Advantage Implementing AUC in NextGen EHR

TempDev NextGen EHR consultants are experts in all regulatory aspects of the EHR, including changes to CMS guidelines. Their partnership with NextGen Healthcare, a leading provider of EHR and EMR platforms, makes them an excellent resource during this significant CMS regulatory changes.

Their NextGen EHR expertise is extremely valuable when implementing the changes made for AUC. AUC implementation will be a significant workflow change for your physicians, especially during the first years of the program. When you work with TempDev, their expert staff can ensure that your NextGen EHR is optimized to fully be able to meet the expectations of the AUC program. As NextGen Healthcare releases new functionality, TempDev will ensure you are aware of all upcoming releases and details.

You and your providers will naturally worry about making mistakes that may impact your reimbursement. The TempDev consultants can alleviate that fear by ensuring that all settings and configurations are correct and in line with AUC regulations.

TempDev can also perform NextGen template development to create customized changes to existing templates so that your workflow doesn't suffer from gaps during AUC implementation. Also, TempDev NextGen EPM consultants can review claims data to make sure it includes the required details.

Final Thoughts

Providers are rightfully nervous about the CMS AUC policy since it will affect how they practice medicine. Some physicians may limit the tests they order for fear of being labeled an outlier. Others may simply mishandle the consultation requirements.

A change of this magnitude can profoundly affect your practice, particularly if you enter 2021 unprepared. Now is the time to have your staff use the testing program to learn the new system's details. TempDev stands ready to answer any questions you have on AUC and to help you prepare NextGen EHR for this change. With the right training, NextGen EHR, and TempDev, you and your staff will be ready for a seamless entry into the AUC protocol. Contact TempDev at 888.TEMP.DEV or here to get started ensuring compliance.


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