Appropriate Use Criteria

April 17, 2019 1:29 PM | Sally Winkelman (Administrator)

Lisa Maurer, MD
Immediate Past President, WACEP

As a part of replacing the Sustainable Growth Rate (SGR), CMS has deemed that we must start reviewing "appropriate use criteria" (AUC) before ordering any CT, MRI, PET, or nuclear medicine studies (does not apply to Xray, U/S).  The American College of Radiology (ACR) has been approved as an eligible group to participate in defining what is and isn’t “appropriate.” 

Starting in 2021, if an ordering physician does not demonstrate through an EHR Clinical Decision Support tool (CDS) that they have consulted the AUC for the study your ordering, CMS will not reimburse the professional or technical charges for the study. 

To clarify, you have to review the AUC, but not necessarily adhere to them.  Emergency physicians will find it to be important because CMS also gives radiologists the green light to refuse to do the studies for which appropriateness criteria were not reviewed.  This system is already in place in the ambulatory care setting.  It will be implemented in the emergency department in less than a year, on Jan 1 2020, but the first year is for "education and operations" and no claims will be denied.  As patterns amongst insurers normally happen,  we can certainly expect commercial insurers to follow suit soon thereafter.  This follows a trend happening for having higher standards for "indications" for studies we order, as already evidenced by our dropdown boxes, etc when you order any image. How this will work in practice for testing from the ED is unclear.

  1. These criteria do not apply for patients that have an Emergent Medical Condition as defined by EMTALA.  However, this is a rather high bar that arguably some of our patients do not meet, and we all know the reputations of payors for determining if care was "emergent" based on final diagnosis rather than presenting symptoms.  
  2. The regulations released from CMS specifically name EDs as being a place of service where these AUC apply. 

Given the above somewhat conflicting information, our hospitals will likely roll this out for all CTs, V/Qs, and MRIs that are ordered from the ED, not excluding patient care that we determine in the moment to be for someone having a true Emergent Medical Condition. 

What will this actually look like in real practice?  It would be reasonable to expect a more extensive clicking process as you enter the order rather than just choosing the indication in a drop down.  In order to minimize impact on workflow, ideally it would just be a modified drop down to choose the most applicable (predetermined to be appropriate) criteria, with an additional option to demonstrate that you have reviewed the criteria and feel it appropriate to deviate from them.  Hospitals will have to invest in CDS as an adjunct to the EHR, or the existing EHR will have to be updated to meet this need.

Reviewing a couple specific examples of “appropriateness” scores helps to clarify what a future rollout in our workflow may look like.  Take a look at the table from ACR grading various studies looking for aortic dissection.  Graded on evidence for utility and radiation exposure.  Doing a PET scan, for example, would be considered "usually not appropriate" but MRA/CT/echo would all be considered "usually appropriate." 

For a more common example, consider head CT imaging for head injury.  ACR describes that a noncontrast head CT is “usually not appropriate” for patients with GCS of at least 13 that do not meet criteria for imaging based on New Orleans Criteria, Canadian CT Head Rules, or NEXUS II guidelines.  However, if GCS is less than 13 or if imaging is indicated based on the above listed guidelines, then the head CT is “usually appropriate.” 

What should you do now?  Contact your hospital administrators to see how they are planning to meet this requirement:

  1. Prevent this from creeping to other imaging study orders such as X-rays, ultrasounds, etc. 
  2. Make sure that whatever EHR adaptations are done are sensical and workable.  ACEP recommends the CDS created by the ACR, called "ACR Select."  We should not be expected to access an external web portal for our CDS, which also exist.  
  3. If the workflow is clunky, we need to have a process in place to bypass choosing criteria for studies that must be done immediately for critically ill patients. 

References:
ACEP summary article from March 2017 (link)
ACR site for CDS (link
Complete list of ACR appropriateness criteria organized by clinical topic (link)