Learn more about the CMS Appropriate Use Criteria Program
Explore our FAQs below to learn more about the CMS Appropriate Use Criteria Program, and discover how AIM Inform simplifies your compliance with it. If you have additional questions, contact Scott Cowsill, senior director of clinical decision support; he will respond within 48 hours.
What is the CMS Appropriate Use Criteria Program?
CMS was directed to establish a program to promote appropriate use criteria (AUC) for outpatient advanced imaging as part of the Protecting Access to Medicare Act of 2014 (PAMA). The goal of the program is to improve the quality of care and reduce inappropriate imaging for Medicare fee-for-service beneficiaries.
To comply with the program, providers need to consult CMS-approved AUC through a qualified clinical decision support mechanism (qCDSM), or tool, when ordering imaging services for these beneficiaries.
Appropriate use criteria are defined by organizations that are designated by CMS as provider led entities. Technology vendors, including AIM, have applied to CMS to be a qCDSM.
What are appropriate use criteria (AUC)?
PAMA defines AUC as "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 decision for a specific clinical condition for an individual."
In essence, AUC are evidence-based guidelines used by providers to assess the clinical appropriateness of certain advanced imaging services, such as CTs and MRIs, for Medicare fee-for-service beneficiaries.
CMS requires that the criteria address, at a minimum, eight priority clinical areas (listed below), which are clinical scenarios associated with some of the most frequently billed codes in Medicare.
- Coronary artery disease (suspected or diagnosed)
- Suspected pulmonary embolism
- Headache (traumatic and nontraumatic)
- Hip pain
- Low back pain
- Shoulder pain (to include suspected rotator cuff injury)
- Cancer of the lung (primary or metastatic, suspected or diagnosed)
- Cervical or neck pain
What is a provider led entity (PLE)?
CMS has defined a PLE as follows: "A PLE would include national professional medical specialty societies (for example the American College of Radiology and the American Academy of Family Physicians) or an organization that is comprised primarily of providers and is actively engaged in the practice and delivery of healthcare (for example hospitals and health systems)."
CMS-designated PLEs develop, or endorse, the appropriate use criteria for the program.
In 2016, CMS identified the following 11 organizations as PLEs:
- American College of Cardiology Foundation*
- American College of Radiology
- Brigham and Women's Physicians Organization
- CDI Quality Institute (in collaboration with AIM Specialty Health)*
- Intermountain Healthcare
- Massachusetts General Hospital, Department of Radiology
- National Comprehensive Cancer Network*
- Society for Nuclear Medicine and Molecular Imaging
- University of California Medical Campuses
- University of Washington Physicians
- Weill Cornell Medicine Physicians Organization
*Clinical content from these PLEs will be included in the AIM CDSM
The PLE designation lasts for five years, and PLEs can reapply for the designation. As of this writing, two of the PLEs – Brigham and Women's and University of Washington – have decided not to continue participation.
What is a qualified clinical decision support mechanism (CDSM)?
CMS envisions CDS mechanisms to be interactive tools that communicate AUC to the user. These mechanisms must make available to the ordering professional applicable AUC and supporting documentation for the applicable imaging service ordered. It is expected that the mechanisms will either be stand-alone portals or offer EMR-integrated capabilities. On July 13, 2017, CMS designated AIM as a qualified CDSM, enabling us to deliver AUC to providers when they order outpatient advanced imaging for Medicare fee-for-service beneficiaries. Our qualified CDSM is available through AIM Inform and, at no charge, through our ProviderPortalSM.
Which modalities are considered advanced diagnostic imaging services?
Advanced diagnostic imaging services include diagnostic MRI, CT, nuclear medicine (including PET), and other diagnostic imaging services that CMS determines in consultation with physician specialty organizations and other stakeholders. Advanced diagnostic imaging services exclude X-ray (including mammography), ultrasound, and fluoroscopy services.
How is AIM involved in the CMS Appropriate Use Criteria Program?
AIM is deeply involved in the CMS program. We have developed appropriate use criteria (AUC), and we are a qualified clinical decision support mechanism (CDSM).
To develop the criteria, we collaborated with the Center for Diagnostic Imaging Quality Institute, a nonprofit affiliate of Center of Diagnostic Imaging and a CMS-designated provider led entity. Our collaboration with them allows us to license and use the AUC.
To become a qualified CDSM, we applied to CMS as required. On July 13, 2017, CMS recognized our commitment to clinical excellence and evidence-based care by designating us as a qualified CDSM. The designation enables us to deliver the AUC to providers through AIM Inform. Providers can also access the criteria and confirm program compliance through our ProviderPortalSM at no charge.
Can my practice use the CMS clinical decision support (CDS) mechanism instead of prior authorization?
No, neither the CMS program nor a CDS mechanism is a substitute for prior authorization of advanced imaging services. Prior authorization and the CMS program are distinct requirements.
The CMS program applies only to Medicare fee-for-service patients; it does not apply to Medicare Advantage or other commercially insured patients that health plans cover today.
AIM Inform, though, allows providers to fulfill prior authorization and the CMS program requirements from a single source. Here's how it works:
When you use AIM Inform to order outpatient advanced imaging, AIM Inform automatically uses patient information in the EMR to determine whether the patient is a health plan member or a Medicare fee-for-service beneficiary. If the patient is a health plan member covered under a program that requires prior authorization through AIM, AIM Inform launches that clinical appropriateness review process within the EMR; if the patient is a Medicare fee-for-service beneficiary, AIM Inform initiates the CMS CDS review. Then, AIM Inform renders a prior authorization decision or confirms that the physician met the CMS program requirement.
What is AIM Inform?
AIM Inform is the integrated solution that simplifies managing the cost and the quality of care.
Integrated into EMR systems that clinicians use every day, the solution enables completion of health plan prior authorization for outpatient advanced imaging and compliance* with the CMS Appropriate Use Criteria Program from a single source. As a result, clinicians achieve real-time payment clarity and clinical determination at the point of care.*AIM Inform is a CMS-qualified clinical decision support mechanism and delivers CMS-approved appropriate use criteria.
How does AIM Inform work?
AIM Inform increases the efficiency of the prior authorization workflow and reduces the need for multiple administrative staff. With AIM Inform, the ordering physician can handle any clinical input while administrative staff will typically be needed only to input nonclinical details, such as selecting an imaging facility.
What modalities does AIM Inform address?
For prior authorization, AIM Inform currently reviews requests for advanced-imaging modalities, including CT, MRIs and MRAs, PET, and MPI. In 2018, AIM Inform will be able to review requests from other clinical areas, including medical and radiation oncology, musculoskeletal and pain management, cardiology, specialty drugs, sleep medicine, and genetic testing.
For the CMS program, AIM Inform addresses each of the advanced imaging services that CMS requires: diagnostic MRI, CT, nuclear medicine (including positron emission tomography), and other diagnostic imaging services that CMS determines in consultation with physician specialty organizations and other stakeholders. (CMS currently excludes X-ray [including mammography], ultrasound, and fluoroscopy services.)
What is the difference between AIM Inform and the ProviderPortal?
AIM Inform and the ProviderPortal help you complete similar tasks, but how they fit into your workflow vastly differs.
AIM Inform is integrated into EMR systems. It allows providers to complete prior authorization for advanced imaging and comply with the CMS program from a single source. With AIM Inform, the ordering physician can handle any clinical input while administrative staff are typically needed only to input nonclinical details, such as selecting an imaging facility. In short, AIM Inform embeds right into the provider workflow, requiring no additional log-ins to a separate technology for prior authorization or CMS compliance.
The ProviderPortal is an online platform where providers can obtain prior authorization for a variety of specialty care services, including advanced imaging. Within the portal, providers can also access the appropriate use criteria and receive confirmation that they complied with the CMS program at no charge.
However, to complete prior authorization within the ProviderPortal, most providers rely on a traditional, extensive workflow involving numerous physicians, nurses, and administrative staff to enter clinical details. A similar workflow will likely be necessary to meet the CMS program requirements.
How can my practice access AIM Inform?
You can access AIM Inform through the EMR system that your practice uses every day.
For no charge, you can also access CMS-approved appropriate use criteria in the ProviderPortal, where you'll receive confirmation that you complied with the CMS Appropriate Use Criteria Program.
My organization is working with other providers to form an accountable care organization (ACO). We also rely on other new reimbursement models. Can we use AIM Inform to manage population health?
Absolutely. AIM Inform can help provider organizations, such as ACOs, manage population health in a number of ways. From a single point of access, providers will be able to:
- Manage at-risk patients across all health plans
- Leverage clinical decision support across the enterprise
- Manage CMS Appropriate Use Criteria requirements for Medicare fee-for-service patients
- Automate and ease workflow for payer preauthorization, where AIM has been delegated to provide clinical appropriateness review
Because of AIM Inform's flexibility, we can customize it to meet the unique needs of your organization. For more information, contact Scott Cowsill.
Can AIM Inform help my organization earn credit for the Merit-based Incentive Payment System (MIPS)?
Yes. In its July 2017 announcement, CMS proposed that consulting appropriate use criteria (AUC) for advanced imaging from a qualified clinical decision support mechanism count as a high-weighted improvement activity under MIPS in 2018.
In addition, while CMS has delayed implementation of the MIPS cost category in 2018, the category is slated to make up 30 percent of the MIPS score in future years.
Because AIM Inform helps providers reduce inappropriate advanced imaging, it can boost early adopters' performance in this increasingly important category.