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