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August 29, 2019

The Appropriate Use Criteria Program is Starting in 2020: Learn More and Take Action on Exemption for Emergencies

You may have heard about the upcoming Medicare requirement to consult Appropriate Use Criteria (AUC) through approved clinical decision support mechanisms prior to ordering advanced imaging services. You may have even heard that you have to do this for all your Medicare patients in order to comply with federal regulations. Well, let me provide some context about what this means for you and how ACEP worked to help clarify an exemption for emergencies.

As background, the Protecting Access to Medicare Act (PAMA) of 2014 created the AUC Program, which will eventually require physicians ordering advanced imaging for Medicare beneficiaries to first consult AUC to be able to receive payment. PAMA specifically exempts emergency services defined as an “applicable imaging service ordered for an individual with an emergency medical condition” from the requirements.

The Centers for Medicare & Medicaid Services (CMS) is the federal agency responsible for implementing the program. ACEP has fought hard to get all emergency physicians exempted from the AUC program requirements, and as a result of our advocacy, CMS recently clarified that exemptions granted for an individual with an emergency medical condition include instances where an emergency medical condition is suspected, but not yet confirmed. In other words, if you think your patient is having a medical emergency (even if he or she winds up not having one), you are excluded from the AUC requirements in that particular case. Many of your patients will likely qualify for this exemption since, as you know, it’s often difficult to differentiate whether a patient is experiencing an emergency or non-emergency condition just based on presenting symptoms.

However, many hospitals may not know about the exemption and still think that emergency physicians are required to comply in each individual case. CMS has slowly phased in the program, and starting on January 1, 2020, the program will enter into a testing phase where providers will be expected to comply with the new requirements but will not be penalized for failing to do so. This is a great time to educate your hospital administrators about this important exemption. To help you accomplish this important task, ACEP has created a sample letter which you can personalize and send forward to your hospital administrator.

It is essential that every provider in your hospital understands this exemption and that your hospital doesn’t wind up forcing you and your colleagues to go through the unnecessary step of consulting AUC in possibly emergency situations. Every second matters in emergency care, and patients’ lives shouldn’t be at risk because people are unaware of the exemption or because your hospital does not have processes in place to operationalize the exemption. So, please talk to your colleagues about the exemption and use our sample letter to contact your hospital administrator today!

Until next week, this is Jeffrey saying, enjoy reading regs with your eggs!

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