Appropriate Use Criteria Program - Data Analysis
Guidance for Medicare claims and methodology and background datasets.
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: August 10, 2020
NOTICE: As announced in the CY 2024 Physician Fee Schedule (PFS) Final Rule, effective January 1, 2024, CMS is pausing efforts to implement the AUC program for reevaluation and rescinding the AUC regulations at 42 CFR 414.94, reserving this section for future use. CMS has not specified a timeframe within which implementation efforts will recommence. See pages 79256-79265 of the final rule.
Effective January 1, 2024, providers and suppliers should no longer include AUC consultation information on Medicare FFS claims. Additionally, CMS will no longer qualify PLEs or CDSMs and will remove this information from the AUC website. The claims processing instructions and guidance for the educational and operations testing period will also be removed.
During the CY 2017 Physician Fee Schedule (PFS) rulemaking cycle, the following data were made available to stakeholders to inform their review of priority clinical area proposals. The first list of priority clinical areas was established in the CY 2017 PFS final rule.
Medicare Claims Data Methodology and Background (PDF)
- Data set (ZIP) [non-compliant Excel file]
- Data set (ZIP) [508 compliant HTML file]
CMS engaged the MITRE Corporation (MITRE), which is a CMS Alliance to Modernize Healthcare (CAMH) Federally Funded Research and Development Center (FFRDC) contractor, to begin developing efficient and effective processes for managing current and future health technology assessments. MITRE generated an independent report that presents a summary of findings from 2014 Medicare claims data and utilization of advanced imaging procedures.
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DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.