At its meeting on Sept. 21, 2013, the Board of Directors of the American Association of Orthopaedic Surgeons (AAOS) adopted a new statement of principles on appropriate use criteria (AUC) for orthopaedic imaging services. The AAOS supports the use of AUC and is in the process of incorporating imaging in both clinical practice guidelines and AUC.

Recent efforts to close the in-office ancillary services (IOAS) exception have focused on the perceived overutilization of these services, including imaging services. This statement will provide a guideline for the AAOS to effectively evaluating any legislative proposal that attempts to address the IOAS issue through the use of AUC on orthopaedic imaging services. The complete text of the position statement follows.

Principles on AUC for Orthopaedic Imaging Services
The American Association of Orthopaedic Surgeons (AAOS) is committed to the highest quality of care for patients undergoing musculoskeletal procedures. Appropriate Use Criteria (AUC) is an important step in ensuring the best use of healthcare resources and preventing unnecessary treatments. The AUC specifies when it is appropriate to use a procedure. An “appropriate procedure” is one for which the expected health benefits exceed the expected health risks by a wide margin. AUCs combine the best available scientific evidence with the collective judgment of physicians in order to determine the appropriateness of performing a procedure.

AAOS has been actively involved in promoting appropriate medical decision making and the wise use of healthcare resources. Recently, AAOS joined the Choosing Wisely^® campaign, a project initiated by the American Board of Internal Medicine (ABIM) Foundation, to help consumers and physicians discuss the overuse of particular tests and procedures and to help patients make smart and effective care choices.

In the area of appropriate use criteria, AUC topics are primarily derived from AAOS Evidence-based Clinical Practice Guidelines that establish the effectiveness of various diagnostic tests or procedures for a given disease, disorder, or condition at a population level. AUC then address the patients for whom these procedures are appropriate, given the variations found in everyday clinical practice.

The AAOS AUC uses a version of the RAND/UCLA Appropriateness Method to yield a statement regarding the appropriateness of performing a specific diagnostic test or procedure at the level of patient-specific symptoms. AAOS supports AUC that are developed using evidence-based information in conjunction with the clinical expertise of physicians and clinicians from multiple healthcare specialties. This ensures improvement in patient care and obtaining the best outcomes while considering the subtleties and distinctions necessary in making clinical decisions.

AAOS supports the integration of clinical decision support technology with AUC to allow physicians to identify and monitor their patterns of care and ensure the appropriate use of diagnostic imaging. The orthopaedic community encourages policymakers to support the appropriate use of imaging through a system that:

• Utilizes qualified physician participation and stakeholder groups working cooperatively to develop effective AUC in clinical decision support, reporting, and improvement initiatives
• Uses embedded clinical decision support tools with AUC, including electronic health records (EHRs) and mobile applications, based on AUC developed or endorsed by medical specialty societies
• Focuses initially on advanced diagnostic imaging services that account for a large amount of expenditures under the Medicare and Medicaid programs
• Includes accountability for the use of AUC by both the ordering physician and the rendering provider (point of order and point of service)
• Provides for documentation of the use of AUC by the submission of data to a qualified registry; through a qualified EHR system, web-based interface, or other electronic means; or by the use of new codes or modifiers submitted on claims
• Provides confidential physician feedback and quality improvement strategies at the individual, physician practice, and system level, progressing from local to national tracking
• Measures total utilization of imaging services as well as appropriateness
• Identifies outliers unwilling to change and allows for focused payment modifications or other interventions
• Promotes physician participation in proactive efforts to provide value-based care

Additional Information
Imaging Services