Appropriate Use Criteria Program - Priority Clinical Areas
Guidance for explaining Priority Clinical Areas. CMS finalized the list in the Physician Fee Schedule.
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.
Background
Priority clinical areas are defined in 42 CFR 414.94(b) as clinical conditions, diseases or symptom complexes and associated advanced diagnostic imaging services identified by CMS through annual rulemaking and in consultation with stakeholders.
CMS finalized an initial list of priority clinical areas in the CY 2017 Physician Fee Schedule Final Rule (data used to inform this rule is available at Proposed_Priority_Clinical_Area_Appendix2 (PDF)) and established the list in 42 CFR 414.94(e)(5).
Priority Clinical Areas as of November 2016
- Coronary artery disease (suspected or diagnosed)
- Suspected pulmonary embolism
- Headache (traumatic and nontraumatic)
- Hip pain
- Low back pain
- Shoulder pain (to include suspected rotator cuff injury)
- Cancer of the lung (primary or metastatic, suspected or diagnosed)
- Cervical or neck pain
HHS is committed to making its websites and documents accessible to the widest possible audience, including individuals with disabilities. We are in the process of retroactively making some documents accessible. If you need assistance accessing an accessible version of this document, please reach out to the guidance@hhs.gov.
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.