CMS Will Soon Unleash a New Appropriate Use Mandate

Cardiac imaging is in need of some wrangling. Professional medical associations and universities across the U.S. have developed appropriate use criteria (AUC) for physicians when determining if a patient should go through cardiac testing. However, a group of physicians believe that the AUC “is no longer an idealistic exercise” and a Centers for Medicare & Medicaid Services (CMS)-approved technique will soon be required when evaluating a patient’s need for imaging procedures.

AUC encourages physicians to utilize evidence or expert opinion when deciding if a patient should receive testing while using a three-fold rubric: appropriate (established value), may be appropriate (uncertain value), and rarely appropriate (no clear value). The AUC’s objective is to limit excess costs and improve “the value of imaging in risk stratification and decision making”.

In an opinion piece published in the Annals of Internal Medicine, the authors from several institutions note that starting in 2018, the CMS will implement a section of the Protecting Access to Medicare Act (PAMA) which will require physicians to use Clinical Decision Support Mechanisms (CDSMs) that have been authorized by the government program.

The CMS has devised a list of “priority clinical areas” in terms of advanced diagnostic imaging services, they’re: coronary artery disease (suspected or diagnosed), suspected pulmonary embolism, headache (traumatic and nontraumatic), hip pain, low back pain, shoulder pain, lung cancer (primary or metastatic, suspected or diagnosed), and cervical or neck pain.

How physicians will transition to the new mandate is yet to be understood, and many feel unprepared. "Critical to the success of this effort is the involvement of all stakeholders,” the authors write. “From imaging specialists to primary care providers, training programs, payers, health systems, and patients — to fully realize the benefits of AUC and extend them to other areas of medicine.”