Appropriate Use Criteria Preparedness – Considerations Beyond Technical Setup

Author: Doreen DeGroff

January 2021 is rapidly approaching for hospitals and providers to meet the Appropriate Use Criteria (AUC) program deadline yet many organizations are reporting that the AUC implementation is proving to be more complex than originally anticipated from a technical, operational and application perspective. Adding to that complexity is the recent release of a portion of operational guidelines and claims requirements from the Centers of Medicare Services (CMS).  EHR vendors are moving as quickly as possible to update their system code to accommodate these changes, which in turn makes the compliance effort a moving target for some organizations.

Determining your progress

The development and implementation specific to the AUC requirement should be at the top of your facility’s/facilities’ priority list.  Setting up the technical infrastructure and system applications to accept and transmit this information is just one area of focus in preparing your facility for this requirement.  If you are also not preparing for the operational, measuring and control pieces of this puzzle you may discover new challenges come 2021.

If you can answer yes to the questions below, you are well on your way:

  • We have selected our qCDSM vendor.
  • Our EHR system is up to date or we have scheduled the necessary updates for any code changes necessary to support AUC.
  • We are actively requesting AUC consultation information be included on all appropriate outpatient orders received for imaging services.
  • Our claim forms have been updated to include the proper codes and modifiers in the segments for submission to Medicare.
  • Our staff members have completed training on our internal policies and procedures and system application of AUC criteria.

New policies versus existing policies – an opportunity for confusion

The key to AUC preparation beyond technical setup includes understanding your adoption/ scorecard/ metrics as a facility with the compliance of similar programs already in place.  AUC calls for many of the same decisions, policies and actions that were developed for Medical Necessity and Prior Approval requirements.  The challenge is that the new AUC requirements don’t replace any of these existing programs.  Without clear policy definition, communication and monitoring- your staff can become confused and misunderstand the true requirements needed.  This challenge provides you with a great opportunity to review how these other programs are currently being handled, how your staff is following policy, and identifying issues in the current processes that can be streamlined to benefit your AUC compliance.

In respect to billing, the similarities with other programs also hold true.  You’ll want to assure that claims submitted to Medicare have the appropriate codes and modifiers. This is another opportunity to review and improve your current denial management process. Is your organization actively mitigating these errors and omissions? And if not, how will you ensure they don’t get confused with AUC related denials come 2021?

Baseline submission results plus communication smooths the road to success

Your organization should be developing a good baseline of submission results – this information is essential to ensure you can be penalty free come 2021. In addition, this baseline data is helpful in developing training and communication around AUC requirements and provides a clear picture of where you stand today and how you can identify AUC related denials and/or issues.  Coupling your baseline results with a clear plan for your staff to follow when they hit barriers or have questions will smooth the road to AUC success.

Preparedness makes policy changes easier to implement

Lastly, changes and new guidelines are almost guaranteed between now and 2021. Some of the recent changes or milestones to the AUC requirements include:

  • The AUC Program Education and Testing period began on January 1, 2020. Medicare Authorization Centers (MACs) now accept HCPCS modifiers on claims, however, claims without the modifiers will not be denied until 2021.
  • The AUC score will change to adherence: adheres to AUC, does not adhere to AUC, or there is no AUC applicable.
  • The information from the ordering professional’s consultation with the qCDSM must be appended to the furnishing professional’s claim in order to be paid.
  • Specific exceptions will be allowed:
    1. The ordering provider having a significant hardship.
    2. Situations in which the patient has an emergency medical condition.
    3. As applicable imaging service ordered for an inpatient and for which payment is made under Part A.
  • The K3 segment will be used to report line level ordering professional information on institutional claims.

Having the technical infrastructure in place, a good baseline of results, and a defined communication plan/process will make upcoming adjustments easier to implement.


Learn more with this recorded webcast:  90 Days to AUC Success.

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