CMS criteria for appropriate use of cardiac imaging create confusion around reimbursement
The appropriate use criteria for imaging for coronary artery disease are heterogeneous and sometimes discrepant, creating substantial potential for uncertainty about reimbursement among clinicians seeking to provide their patients with appropriate tests, an analysis found.
The CMS criteria for coronary artery disease (CAD) imaging are inconsistent and unclear, according to a review of the Appropriate Use Criteria (AUC) program.
Researchers reviewed websites for the authorized provider-led entities (PLEs) focused on advanced imaging tests for CAD, a “priority clinical area” for CMS. AUC were collected by an internet search on Aug. 29, 2022. Results were published Aug. 22 by Annals of Internal Medicine.
Of the 17 current CMS-qualified PLEs, two did not have any published AUC available online. Eight had published AUC but did not have any relevant to CAD. In some cases, the PLE was focused on other clinical priority areas such as back pain or cancer care, or the PLE was newly qualified and had not yet published any AUC. The remaining seven PLEs, three professional societies, two medical center/university practice groups, one radiology services network, and one unaffiliated organization, varied substantially in AUC methods and formatting. The number of clinical scenarios covered ranged from six to 210, and the number of advanced imaging methods covered ranged from one to 25. When specifically applied to clinical scenarios, many AUCs offered no guidance on appropriateness; those that did conflicted with one another on the issue.
The study authors noted that the current patchwork of AUC from different PLEs may leave frontline clinicians uncertain about whether the care they are delivering will ultimately be reimbursed by CMS. Possible changes to the current program could including restricting CMS approval of PLEs to medical societies, academic institutions, or organizations with an established track record of producing AUC published in peer-reviewed scientific journals; approving narrower AUCs for a single priority clinical area; or requiring all PLEs for a priority clinical area to work collaboratively on creating a single unified AUC.
“In light of the substantial heterogeneity of PLE-derived AUC and subsequent frontline clinician uncertainty about CMS reimbursement for advanced imaging tests they perform, it seems reasonable to question whether the AUC program as currently designed needs considerable modification, or even full repeal,” the authors wrote.