In the Public Affairs article of the March/April 2018 CMA Today, I argued that “appropriately educated and credentialed medical assistants” such as CMAs (AAMA)® are clinical staff under the Medicare Chronic Care Management (CCM) and Transitional Care Management (TCM) programs.1 The purpose of this issue’s article is to demonstrate that CMAs (AAMA) are also clinical staff according to the Centers for Medicare & Medicaid Services (CMS) rule regarding the appropriate use criteria (AUC) program. Therefore, as a result of their clinical staff status, I assert that CMAs (AAMA) are permitted to do the following:

  1. Consult a clinical decision support mechanism (CDSM) about the appropriateness of ordering a particular advanced diagnostic imaging service
  2. Report findings to their overseeing or delegating licensed providers

The AUC program

By enacting the Protecting Access to Medicare Act of 2014 (PAMA), Congress authorized the creation of a Medicare program that would discourage the inappropriate and unnecessary ordering of advanced diagnostic imaging services:

  • Magnetic resonance imaging (MRI)
  • Nuclear medicine
  • Positron emission tomography (PET)
  • Computed tomography (CT)

The Protecting Access to Medicare Act directed CMS to promulgate AUC for these advanced imaging services to give ordering providers guidance on which imaging services are most appropriate for various medical conditions. The CMS rule defines AUC as follows:

Appropriate use criteria (AUC) means criteria … developed or endorsed by national professional medical specialty societies or other provider-led entities, to assist ordering professionals and furnishing professionals in making the most appropriate treatment decision for a specific clinical condition for an individual. To the extent feasible, such criteria must be evidence-based. An AUC set is a collection of individual appropriate use criteria. An individual criterion is information presented in a manner that links: a specific clinical condition or presentation; one or more services; and, an assessment of the appropriateness of the service(s).2

Medical assistants should note that the AUC program is applicable to outpatient settings2:

  • Physician’s office
  • Hospital outpatient department (including an emergency department)
  • Ambulatory surgical center
  • Independent diagnostic testing facility
  • Any other provider-led outpatient setting determined appropriate by the U.S. Secretary of Health and Human Services

Certain services and settings are exempt from the AUC program, such as inpatient services, services provided to individuals with an emergency medical condition,3 and services in a critical access hospital (CAH).4

Significantly, Medicare reimbursement for advanced diagnostic imaging services may be denied if there is noncompliance with the requirements of the AUC program.

Clinical decision support mechanism

A key operational component of the AUC program is the requirement that licensed providers (or their clinical staff) consult a CDSM that meets CMS specifications before ordering an advanced diagnostic imaging service. A CDSM is defined in the CMS rule as follows:

Clinical decision support mechanism (CDSM) means the following: an interactive, electronic tool for use by clinicians that communicates AUC information to the user and assists them in making the most appropriate treatment decision for a patient’s specific clinical condition. Tools may be modules within or available through certified EHR [electronic health record] technology (as defined in section 1848(o)(4)) of the [Protecting Access to Medicare] Act or private sector mechanisms independent from certified EHR technology or established by the Secretary [of Health and Human Services].3

Which personnel should be allowed to do a CDSM consultation?

There was considerable debate during the rule-making process about which personnel should be permitted to perform the CDSM consultation. In response to the proposed AUC program rule, some commenters expressed the opinion that only licensed providers should be allowed to consult the CDSM. Other commenters thought that any staff members should be able to do so. Additionally, CMS summarized a third position of commenters:

These commenters stated that the AUC consultation should not be an administrative task that can be performed by any staff member, such as a receptionist or data entry clerk. The underlying concern of commenters that wanted to explicitly allow only clinical personnel to consult AUC was that the individual performing an AUC consultation would need to understand the patient’s medical information, the advanced imaging service being recommended and the clinical information that is returned by the CDSM. Commenters stated that this understanding on the part of the individual who performs the AUC consultation was particularly important when a CDSM indicates that the order is not adherent to AUC.5

After reviewing the comments, CMS came to the following conclusion in its final rule:

When not personally performed by the ordering professional, the consultation with a qualified CDSM may be performed by clinical staff under the direction of the ordering professional. We have used the term clinical staff elsewhere in the Medicare program to identify the individuals that may perform care management services including chronic care management (CCM), behavioral health integration (BHI) and transitional care management (TCM) services. These services involve some non-face-to-face services along with clinical activities around the care plan and communication and coordination with the patient’s other healthcare professionals. For care management, the clinical staff requirement ensures that the individual performing the service must have the level of clinical knowledge necessary to effectively coordinate and communicate with the treating clinician. Similarly, in the case of the AUC program, the individual performing the AUC consultation must have sufficient clinical knowledge to interact with the CDSM and communicate with the ordering professional. After considering public comments on our proposal, we have concluded that allowing clinical staff to perform the AUC consultation under the direction of the ordering professional is a better fit with the AUC program than our [initial] proposal. … We believe the policy we are finalizing, to allow the AUC consultation to be performed by clinical staff under the direction of the ordering professional, further reflects a balance between those commenters who wanted only the ordering professional to perform the consultation and those who suggested we should allow the consultation to be delegated. Clinical staff will have a level of knowledge that allows for effective communication of advanced diagnostic imaging orders, interaction with AUC, and engagement with the ordering professional, while they remain under the direction of the ordering professional.5 [Emphasis added.]

How the CMA (AAMA) meets the requirements

Medical assistants who are current CMAs (AAMA) have met the following requirements for CMA (AAMA) certification:

  1. Completed a postsecondary (college-level) education that includes essential clinical knowledge
  2. Passed the CMA (AAMA) Certification Exam that tests clinical knowledge (in addition to other essential areas of knowledge)
  3. Provided evidence of current mastery of such clinical knowledge every five years by either completing at least 10 hours of clinical continuing education (out of a total of 60 hours of continuing education) or passing the CMA (AAMA) Certification Exam again

Therefore, I maintain that CMAs (AAMA) are clinical staff under the AUC program and consequently are authorized to perform a CDSM consultation and communicate with the ordering providers about the appropriateness of various advanced diagnostic imaging services for specific patients with specific conditions.

The AUC program is scheduled to begin January 1, 2020, with a one-year testing and learning period during which no Medicare claims for advanced diagnostic imaging services will be denied. The AUC program is scheduled to be implemented fully on January 1, 2021, with denial of claims for noncompliance. However, CMS has the authority to postpone these starting dates. Updates will be available in CMA Today and on the AAMA website: www.aama-ntl.org.

Questions may be directed to CEO  and Legal Counsel Donald A. Balasa, JD, MBA, at dbalasa@aama-ntl.org, or 800/228-2262.