What are appropriate use criteria (AUC) and why are we hearing about them now? According to the Centers for Medicare and Medicaid Services (CMS), AUC are “criteria that are evidence-based (to the extent feasible) and assist professionals who order and furnish applicable imaging services to make the most appropriate treatment decisions for a specific clinical condition.” ACEP has been working behind the scenes for the past two years in response to legislation which was passed in 2014. And yes, this is another burden that emergency physicians will have to shoulder beginning January 2018, when penalties (eg, Medicare payment denials) are scheduled to begin.
However, it may also have some benefit and help us care better for our patients.
The “Protecting Access to Medicare Act of 2014” (PAMA) included several provisions to slow the growth of Medicare costs, and one provision is AUC, where doctors ordering certain tests will be required to use clinical decision support (CDS) tools (eg, via embedded software in the electronic health record) for advanced imaging (defined as MRI, CT, nuclear medicine, and PET). Plain X-ray, fluoroscopy, and ultrasound exams are not currently included.
Practically, this law is part of a much larger effort to employ standardization (reduce variability) in clinical practice by targeting high use and/or high cost services. Three years after the regulations are implemented, physician “outliers” will be identified and notified that they are subject to preauthorization when ordering advanced imaging tests.
Is AUC applicable in the Emergency Department and What Steps Has ACEP Taken?
Yes, AUC will apply in the emergency department. Although PAMA explicitly includes the emergency department as a setting where AUC would apply, the law and enabling regulations state that if an individual has an emergency medical condition (EMC; as defined under EMTALA), the physician can forgo consulting the criteria. The key operative word is “has,” because it does not exempt patients who have not yet been determined to have an EMC.
ACEP protested this illogical interpretation: In order to determine that an EMC exists, certain tests, including advanced imaging, may be needed. As President of ACEP, Dr. Kaplan went to multiple meetings in Washington and Chicago to discuss this definition and what could be done to simply exempt the emergency department setting from this regulation. The argument was that EMTALA was in direct conflict with the interpretation of the PAMA law: EMTALA requires us “to use all measures to determine if a medical condition is an emergency medical condition as defined by EMTALA and as required by federal law” without any barriers to block that process; PAMA creates a barrier to doing so. A two-year series of comment letters and meetings with CMS officials ensued. We even went back to the bill’s author, Rep. Pitts, who wrote to CMS asking for a correction to what was a legislative drafting mistake. CMS did not make that change but did acknowledge our points. At the same time, they expressed concern about giving emergency physicians carte blanche to potentially “overuse” advanced imaging. The 2017 Medicare Physician Fee Schedule included revised language that provided more weight for clinical judgement by emergency physicians (see sidebar).