Appropriate Use Criteria for Advanced Imaging
On January 1, 2020, Congress imposed new requirements for ordering advanced imaging services (MRI, CT, PET and Nuclear Medicine services) for Medicare beneficiaries.
What the new law means for you
Providers: When ordering advanced imaging services you will be required to show that you have consulted appropriate use criteria (AUC) through a Centers for Medicare and Medicaid Services approved Clinical Decision Support Mechanism (CDSM). This requirement applies in all outpatient and emergency settings and was imposed as an alternative to requiring prior authorization for these services. CMS will collect data on whether your orders adhere to the recommendations of the AUC. Using a look-back period still to be defined, CMS will use these data to identify outliers who will eventually be subject to third-party preauthorization of imaging for Medicare patients.
Patients: You will not be required to do anything differently. You are more likely to get the correct imaging study for your symptoms.
The Johns Hopkins advantage
Better AUCs: Johns Hopkins is one of 22 provider-led entities in the U.S. approved by the Centers for Medicare & Medicaid Services (CMS) to develop AUCs. Multidisciplinary teams of Hopkins providers have created a limited number of AUCs based on high quality evidence to ensure that our patients benefit from the right study, performed the right way, at the right time.
Fewer Interruptions: Johns Hopkins has developed a workflow to integrate a CMS approved clinical decision support mechanism within Epic and CareLink to create a seamless ordering experience that complies with the new law and associated regulations. Ordering through one of the decision-tree guidelines designed by teams of Hopkins faculty ensures that all of your orders will be adherent to our AUCs. Alternatively, if you place a direct order for advanced imaging at a Hopkins imaging site through Hopkins Epic or Hopkins CareLink, the AUC consultation will occur in the background for most orders, minimizing interruptions to ordering provider workflow. An actionable alert will fire only if an order contravenes one of the few, high quality Hopkins AUCs and the software engine can’t find evidence in the patient’s medical record that reflects an appropriate indication. There are no hard stops, so when an alert fires providers may opt to proceed or change an order. We have worked very hard to design a system that promotes appropriate imaging while minimizing non-actionable alerts or interruptions; other imaging sites may launch AUCs for every advanced imaging study, resulting in numerous workflow interruptions for alerts that are not actionable.
Frequently Asked Questions
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Providers using Johns Hopkins EPIC will see the new workflow beginning January 2020.
Providers using Johns Hopkins CareLink will see the new workflow later in 2020.
Johns Hopkins imaging sites will still accept paper referrals until January 2021.
We will support you in the ordering process and provide more details through our physician liaisons.
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No, if you order through Johns Hopkins Epic or Johns Hopkins CareLink. While the new law requires the ordering professional to provide additional information* with each order for advanced imaging services, Johns Hopkins Epic and Johns Hopkins CareLink will capture the required information automatically and pass it on to our revenue cycle module on your behalf.
*The required information includes your national provider identifier, the approved CDSM you utilized, which AUC you consulted (or that no AUC was applicable), and whether the order adhered to the AUC or not.
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The new regulations require ordering professionals or clinical staff under the direction of the ordering professional to consult the applicable AUC through a qualified CDSM. If an ordering professional delegates the consultation to clinical staff, the individual performing the AUC consultation must have sufficient clinical knowledge to interact with the CDSM and communicate with the ordering professional.
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CMS regulations require that the AUCs presented to ordering providers through a qualified CDSM address, at a minimum, the following priority clinical areas:
- Coronary artery disease (suspected or diagnosed)
- Suspected pulmonary embolism
- Headache (traumatic and nontraumatic)
- Hip pain
- Low back pain
- Shoulder pain (including suspected rotator cuff injury)
- Cancer of the lung (primary or metastatic, suspected or diagnosed)
- Cervical or neck pain
As a qualified provider-led entity authorized to create AUCs, Johns Hopkins has created a limited number of AUCs that address these priority clinical areas. Our AUCs were created by multidisciplinary teams of Johns Hopkins physicians using high quality evidence. These AUCs are tailored to the emergency department and ambulatory settings. Johns Hopkins will periodically update and improve its AUCs to ensure the quality and appropriateness of the advanced imaging services we provide for all of our patients, and we may create AUCs for other conditions beyond the priority clinical areas in its own discretion.
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Johns Hopkins has created ordering workflow for advanced imaging in Johns Hopkins Epic and Johns Hopkins CareLink that will apply to all orders regardless of their insurance coverage. We do not treat patients differently based on their insurance coverage.
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No, ordering providers are not required to consult AUC for non-advanced diagnostic exams like radiographs and ultrasounds. The legislation only requires AUC consultation for advanced diagnostic imaging services (MRI, CT, PET and Nuclear Medicine).
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No, our radiology reports for the ordering provider will remain in the same format with no changes in language, design or turnaround time.
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Please contact the physician liaison for the Johns Hopkins Medical Imaging location you most frequently refer to for imaging studies. We are happy to help you during this transition.
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Johns Hopkins faculty members are leading experts on appropriate imaging. Our radiology faculty members, along with other national experts, have created free targeted lectures for referring providers on appropriate imaging for priority clinical areas and more.
More information is available on the CMS AUC Program website and through numerous publications, including:
Hentel, KD, et.al; What Physicians and Health Organizations Should Know About Mandated Imaging Appropriate Use Criteria, Ann Intern Med. 2019; 170 (12): 880-885.