APPROPRIATE USE CRITERIA – PROGRAM IMPLEMENTATION IS COMING
Appropriate Use Criteria (AUC) for advanced diagnostic imaging – this topic has been looming for the past couple of years as voluntary participation in the program began in 2018. However, with mandatory program participation starting in a few months and more guidance and information being recently released from the Centers for Medicare and Medicaid Services (CMS), it’s time to prepare yourself for the coming implementation.
PROGRAM BACKGROUND
The Protecting Access to Medicare Act (PAMA) of 2014 included a section that “established a new program to increase the rate of appropriate advanced diagnostic imaging services furnished to Medicare beneficiaries” (MLN Matters Article 11268). This program requires that professionals ordering advanced diagnostic imaging services for Medicare patients consult a qualified Clinical Decision Support Mechanism (CDSM) prior to ordering the test to ensure tests being ordered adhere to established AUC.
The servicesimpactedby this program are MR imaging, CT and nuclear medicine (including PET). A full list of the impacted procedure codes may be found in the recently released Claims Processing Instructions.
RADIOLOGY PROVIDERS – WHAT THIS MEANS FOR YOU
Effective January 1st, the AUC/CDSM information must be communicated on the test order from the ordering professional, and that information must be reported on claims submitted for impacted services. Radiology providers need to be ensuring all orders being received for advanced imaging services include the CDSM information when the service is ordered.
2020 is a testing period, meaning CMS will not be denying claims submitted if the AUC information is not reported or if it is reported incorrectly. However, full program implementation is on track for January 1, 2021 – when this happens radiology providers will not be paid for Medicare claims submitted without the AUC/CDSM information.
It is strongly encouraged that radiology providers participate during this testing period and work with ordering professionals to make sure the necessary information is being communicated on the order. It’s radiology revenues at stake with this program implementation, make sure you are protected and minimizing risk now.
MOVING FORWARD
To report AUC information, CMS released eight new HCPCS modifiers to be reported on the same line as the appropriate CPT® code.
| CDSM Not Consulted – Emergency | |
|---|---|
| MA | Ordering professional is not required to consult a CDSM due to service being rendered to a patient with a suspected or confirmed emergency medical condition |
| CDSM Not Consulted – Hardship | |
| MB | Ordering professional is not required to consult a CDSM due to the significant hardship exception of insufficient internet access |
| MC | Ordering professional is not required to consult a CDSM due to the significant hardship exception of electronic health record or CDSM vendor issues |
| MD | Ordering professional is not required to consult a CDSM due to the significant hardship exception of extreme and uncontrollable circumstances |
| CDSM Consulted | |
| ME | The order for this service adheres to the AUC in the CDSM consulted by the ordering professional |
| MF | The order for this service does not adhere to the AUC in the CDSM consulted by the ordering professional |
| MG | The order for this service does not have AUC in the CDSM consulted by the ordering professional |
| Unknown | |
| MH | Unknown if the ordering professional consulted a CDSM for this service, related information was not provided for the furnishing professional or provider |
In addition to the HCPCS modifiers for AUC, G-codes have also been established to report the qualified CDSM consulted by the ordering professional. The appropriate G-code should be reported as a separate line item when claims are submitted with a HCPCS modifier indicating CDSM was consulted (ME, MF, MG). Note: these G-codes do not have associated payment rates, they are for reporting purposes only. A full list of the G-codes, additional information on the modifiers listed above and additional processing instructions can be found here.
STAY UPDATED
As with any new program implementation, there are lingering questions – one of the big questions still remaining is, even though claims are not to be denied during this testing period, will there be penalties for not participating in the program or not attempting to consult CDSM during this testing year? For now, the answer is unknown. Watch for more information to be released as we get closer to 2020.
What we do know is that January 2021, claims submitted for advanced imaging services furnished to Medicare patients will not be paid without AUC/CDSM information reported on the claim. Make sure your revenues aren’t at risk.
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