InsightsRadiology

Appropriate Use Criteria (AUC) Program Implementation – What’s Happening in 2021?

The release of the Medicare Physician Fee Schedule (MPFS) CY2021 proposed rule on August 3rd contained a lot of information for radiology providers to digest (a proposed 10.61% reduction to the conversion factor for 2021!), but there was also a noticeable absence in the proposed rule – any discussion of the Appropriate Use Criteria (AUC)/Clinical Decision Support (CDS) mandate for advanced diagnostic imaging services.

Currently, this program is in an operations and testing period that is set to expire on 12/31/2020, with full program implementation scheduled to take place on 01/01/2021. During this operations and testing period, radiology providers were encouraged to work with their referring physicians to ensure AUC/CDS information was communicated, and to begin reporting that information on claims. During this operations and testing period, claims lacking this information are not being denied.

With the full program implementation scheduled for 01/01/2021, payment denials would become a reality for advanced diagnostic imaging services when claims are submitted without AUC/CDS information. This is where the exclusion of any discussion regarding this full program implementation becomes glaring for radiology providers. Until any further detail is provided, it is important to move forward with preparation for this program to be fully implemented beginning January 1st.

This implementation, coupled with the proposed payment decreases for radiology in the proposed rule, could set radiology providers up for a difficult new year.

AUC/CDS Program Refresher

The Protecting Access to Medicare Act (PAMA) of 2014, Section 218(b), established a new program designed to raise the rate of appropriate ordering of advanced diagnostic imaging services provided to Medicare beneficiaries. 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.

Under this program, advanced diagnostic imaging services include:

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

A full list of the advanced imaging procedure codes can be found within the claims processing guidance released by the Centers for Medicare and Medicaid Services (CMS).

CDS is a tool for physicians to use during the evaluation of a patient to communicate AUC information to them and aid them in making appropriate decisions for treating the patient’s clinical condition. The CDS tool lets the ordering professional know whether or not the test being ordered adheres to established AUC, or if there is no AUC applicable to address the patient’s condition.

Additionally, information regarding the CDS consulted and adherence to AUC must be communicated on the test order from the ordering professional to the provider furnishing the imaging services. Providers are able to access imaging AUC through a stand-alone CDS system or using CDS software incorporated into their electronic health record system.

Overall, note that claims for advanced diagnostic imaging services must include:

  • The ordering professional’s national provider identifier (NPI)
  • Which CDS tool was consulted among the multiple qualified options available
  • Identification of if the service ordered would or would not adhere to consulted AUC or if the consulted AUC was designated as not applicable to the ordered service.

Modifiers and Codes for Reporting

The claims processing instructions released by CMS for reporting AUC/CDS information includes eight modifiers, listed below, which are to be reported on the same line as the CPT® code for the imaging service. If furnishing providers do not receive AUC information from the ordering provider, that should be reported with modifier MH.

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 of EHR 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 services, related information was not provided for the furnishing professional or provider

In addition, eleven G-codes were created to report the CMS-approved, qualified CDS tool consulted by the ordering professional, plus one code for qualified tool, not otherwise specified. The appropriate G-code should be reported as a separate line item when claims are submitted with a HCPCS modifier indicating CDS was consulted (ME, MF, MG). It is acceptable to report multiple G-codes on a single claim. Note: these G-codes do not have associated payment rates, they are for reporting purposes only.

G1000   Clinical Decision Support Mechanism Applied Pathways, as defined by the Medicare Appropriate Use Criteria Program

G1001   Clinical Decision Support Mechanism eviCore, as defined by the Medicare Appropriate Use Criteria Program

G1002   Clinical Decision Support Mechanism MedCurrent, as defined by the Medicare Appropriate Use Criteria Program

G1003   Clinical Decision Support Mechanism Medicalis, as defined by the Medicare Appropriate Use Criteria Program

G1004   Clinical Decision Support Mechanism National Decision Support Company, as defined by the Medicare Appropriate Use Criteria Program

G1005   Clinical Decision Support Mechanism National Imaging Associates, as defined by the Medicare Appropriate Use Criteria Program

G1006   Clinical Decision Support Mechanism Test Appropriate, as defined by the Medicare Appropriate Use Criteria Program

G1007   Clinical Decision Support Mechanism AIM Specialty Health, as defined by the Medicare Appropriate Use Criteria Program

G1008   Clinical Decision Support Mechanism Cranberry Peak, as defined by the Medicare Appropriate Use Criteria Program

G1009   Clinical Decision Support Mechanism Sage Health Management Solutions, as defined by the Medicare Appropriate Use Criteria Program

G1010   Clinical Decision Support Mechanism Stanson, as defined by the Medicare Appropriate Use Criteria Program

G1011   Clinical Decision Support Mechanism, qualified tool not otherwise specified, as defined by the Medicare Appropriate Use Criteria Program

Stay tuned as more information regarding this program, and other provisions in the proposed rule impacting radiology services, becomes available. As always, you can count on our robust library of radiology coding resources to be fully updated with everything you need to know to guide you through the coming year.