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AUC Pivot

By Melody Mulaik

The testing period for Appropriate Use Criteria (AUC) implementation is almost over – well not quite. While there was no information in the Centers for Medicare and Medicaid Services (CMS) Medicare Physician Fee Schedule (MPFS) Proposed Rule released on August 4, 2020, CMS subsequently updated their website to indicate that the educational and operations testing period for the Appropriate Use Criteria (AUC) consultation requirement has been extended through CY2021. This means that there are no payment consequences associated with the AUC program during CY2020 and CY2021.

So, with this information now in hand, what should you do? Push off your implementation plan by a year? Continue with your current plan and use the additional time for testing? Or, hold tight to wait to see if CMS will make a dramatic change and either totally change how reporting is done or somehow find a way to eliminate the requirement entirely? The answer to that depends on your type of organization, how much COVID-19 has impacted you financially and your tolerance for risk.

There is not one right answer to the above quandary. There are pros and cons to each, but it is important that you weigh your options and make an educated decision that is the right fit for your organization. Hospitals and health care systems need as much time as possible to modify their systems, build interfaces and test all the possible scenarios for orders in all of the affected settings by employed and non-employed ordering providers. What might seem like a straightforward process can quickly become complicated when you start laying out all the potential ordering scenarios that could occur in the acute care and outpatient settings.

One suggestion is to separate the IT implementation from the operational implementation. You can build the required systems infrastructure and ensure that you can appropriately submit claims to a wide variety of payers without requiring a mandatory AUC consultation by your ordering providers. This is a very important distinction when you consider how you define implementation timeframes. There are some outstanding questions that CMS need to address with additional guidance. For example, how will radiologists communicate on the claim that an exam was interpreted at a critical access hospital (CAH) and thus exempt from the consultation requirement? It could be tempting to let the unanswered questions prevent you from taking action on the majority of issues that we do have the answers to at this point. That said, it is OK to put some items on hold, but address the greater issues in the project scope.

Don’t be afraid to tackle the challenge of a revised timeline head on. Having open and candid conversations with all of the stakeholders to ensure that there are no surprises at any point in the process is vital to a successful implementation. Don’t apologize for needing time to ensure that all of your required system changes are in place and working correctly.

Melody W. Mulaik, MSHS, CRA, RCC, RCC-IR, CPC, COC, FAHRA, is the president of Revenue Cycle and Coding Strategies Inc.




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