Appropriate Use Criteria Delay Reminder: Quick Review Guidance

In light of the public health emergency (PHE) over the past year, the Centers for Medicare & Medicaid Services (CMS) has suspended plans to implement the Appropriate Use Criteria (AUC) into full implementation mode. Last year on January 1, 2020, the AUC program started a one-year educational and operations testing phase to give providers time to voluntarily participate and prepare. The AUC as mandated by the Protecting Access to Medicare Act (PAMA) 2014, was originally supposed to engage in full implementation on January 1, 2021. Claims which failed to meet the criteria would not be reimbursed. However, CMS announced a delay of one year, extending the testing and operations period through 2021. CMS states “there are no payment consequences associated with the AUC program during CY 2020 and CY 2021. We encourage stakeholders to use this period to learn, test and prepare for the AUC program.” Radiology providers, physicians, and healthcare regulatory and compliance teams should start preparing now to avoid pitfalls when the program implements in 2022.

AUC Regulatory Policy Review

The Protecting Access to Medicare Act (PAMA) of 2014, Section 218(b), designated a new program designed to increase the rate of appropriate ordering of advanced diagnostic imaging services for Medicare beneficiaries. The four key areas of advanced imaging services subject to this rule are:

  • computed tomography (CT)
  • positron emission tomography (PET)
  • nuclear medicine
  • magnetic resonance imaging (MRI)

CMS had stated the AUC policy applies to all the above advanced diagnostic imaging services performed in a “physician’s office, hospital outpatient department (including the emergency department), an ambulatory surgical center or an independent diagnostic testing facility (IDTF) and whose claims are paid under the physician fee schedule, hospital outpatient prospective payment system or ambulatory surgical center payment system.”

The program requires that when a practitioner orders an advanced diagnostic imaging service for a Medicare beneficiary, he/she, or clinical staff acting under his/her direction, are obligated to consult a qualified Clinical Decision Support Mechanism (CDSM). The assessment of AUC occurs through these CDSM electronic portals. Providers can access imaging AUC through a stand-alone CDS system or by using CDS software that is incorporated into their electronic health record system.

The CDSM provides a determination of whether a specific order complies with AUC or if the AUC was not applicable. Not applicable means that no such AUC exits to address the patient’s clinical condition.

CMS has detailed that the processing systems will accept claims containing a current Procedural Terminology (CPT) or HCPCS C-code, with a line item HCPCS modifier appended to explain either the level of compliance to AUC, or an exception to the program, along with a separate line item G-code to describe the qualified CDSM consulted.

During 2021, the program will continue as an education and operations testing period. Over the course of this period, claims will not be denied if they fail to include proper AUC consultation information per the suspension of implementation under the PHE. For 2022, the new timeline for full implementation, failure to comply will be consequential. Expect to receive zero payment on claims that fail to comply. This means that payment will be denied for the professional and technical components along with any charges billed globally.

Claims for advanced diagnostic imaging services should include:

  • The ordering professional’s national provider identifier (NPI)
  • Which  CDSM was consulted among the multiple qualified CDSMs available
    • Identifying 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.

The list is subject to updates. AUC consultation is still required for all advanced diagnostic imaging services and not only those that fall under the priority clinical areas. Master obstacles with more monthly insight into compliance and coding challenges through our Radiology Compliance Manager Newsletter.

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