Appropriate Use Criteria for Advanced Diagnostic Imaging

The Centers for Medicare & Medicaid Services’ (CMS) Protecting Access to Medicare Act of 2014 (PAMA) requirement for advanced imaging services will start impacting our reimbursements on January 1, 2023.

The CMS mandate requires all advanced diagnostic imaging services have to undergo an appropriate use criteria (AUC) consultation through a clinical decision support mechanism (CDSM) for all Medicare patients prior to the completion of the imaging service in order to receive CMS reimbursement.

Advanced Diagnostic Imaging

A qualified scoring system must be consulted when ordering the following Medicare Part B advanced diagnostic imaging services:

  • Computed tomography (CT)
  • Positron emission tomography (PET)
  • Nuclear medicine (NM)
  • Magnetic resonance imaging (MRI)

Priority Clinical Areas

These are clinical conditions, diseases or symptom complexes and associated advanced diagnostic imaging services identified by CMS through annual rulemaking and in consultation with stakeholders. The AUCs presented to ordering providers through a qualified CDSM address the following priority clinical areas:

  • Coronary Artery Disease
  • Suspected Pulmonary embolism
  • Headache
  • Hip pain
  • Low back pain
  • Lung Cancer
  • Cervical/Neck pain
  • Shoulder Pain