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CMS’ Advanced Use Criteria Program No Longer Voluntary Starting January 1, 2020

CMS' Advanced Use Criteria Program No Longer Voluntary Starting January 1, 2020

Starting January 1, 2020, providers who order Medicare Part B advanced diagnostic imaging services are required to consult appropriate use criteria (AUC) through a qualified Clinical Decision Support Mechanism (CDSM). That information must then be provided to furnishing professionals and facilities, who are required to report AUC consultation information on their Medicare claims.

Mandated through the Protecting Access to Medicare Act (PAMA) of 2014, the AUC program was implemented in 2018, when providers were invited to begin participating in the program on a voluntary basis. AUC becomes mandatory on January 1, 2020, though technically the program will operate under an Education and Operations Testing Period for the year. That means claims that do not include AUC documentation will not be denied until January 1, 2021, when the program is expected to be fully operational.

Who, What, Where

For the purposes of AUC, the Centers for Medicare and Medicaid Services (CMS) considers the following to be “advanced diagnostic imaging services”:

  • diagnostic magnetic resonance imaging,
  • computed tomography,
  • nuclear medicine, and
  • positron emission tomography.

Ordering providers bear the burden of consulting one of the CMS-approved CDSMs, which may be available through an integration with the practice’s EHR, and passing along that information to furnishing providers in any of the following applicable settings: 

  • Physician offices.
  • Hospital outpatient departments (including emergency departments).
  • Ambulatory Surgical Centers (ASCs).
  • Independent diagnostic testing facilities.

How to Get Paid

During the voluntary reporting period, ordering and furnishing providers used modifier QQ to indicate that the ordering professional consulted a qualified CDSM for the service and provided the related data to the furnishing professional. Beginning January 1, 2020, however, CMS has established the following HCPCS modifiers for use in the AUC program. One of these modifiers should be added to the same line as the CPT code for the advanced diagnostic imaging service:

  • MA – Ordering professional is not required to consult a clinical decision support mechanism due to service being rendered to a patient with a suspected or confirmed emergency medical condition.
  • MB – Ordering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of insufficient internet access.
  • MC – Ordering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of electronic health record or clinical decision support mechanism vendor issues.
  • MD – Ordering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of extreme and uncontrollable circumstances.
  • ME – The order for this service adheres to the appropriate use criteria in the clinical decision support mechanism consulted by the ordering professional.
  • MF – The order for this service does not adhere to the appropriate use criteria in the qualified clinical decision support mechanism consulted by the ordering professional.
  • MG – The order for this service does not have appropriate use criteria in the clinical decision support mechanism consulted by the ordering professional.
  • MH – Unknown if ordering professional consulted a clinical decision support mechanism for this service, related information was not provided to the furnishing professional or provider.

Claims that include modifiers ME, MF, or MG should additionally contain a G-code (on a separate claim line) to report which qualified CDSM was consulted. A list of G-codes by CDSM are available in the MLN Matters Number MM11268.

AUC Exceptions

As noted above in the list of modifiers, there are some exceptions to the requirement for ordering providers to consult CDSMs. They include:

  • The ordering professional having a significant hardship.
  • An applicable imaging service ordered for an inpatient and for which payment is made under Part A.
  • Situations in which the patient has a suspected or confirmed emergency medical condition.

According to the American College of Emergency Physicians (ACEP), the emergency medical condition exception is particularly noteworthy because it includes both confirmed and suspected emergency medical conditions.

“In other words, if you think your patient is having a medical emergency (even if he or she winds up not having one), you are excluded from the AUC requirements in that particular case,” writes Jeffrey Davis, ACEP’s Director of Regulatory Affairs. “Many of your patients will likely qualify for this exemption since, as you know, it’s often difficult to differentiate whether a patient is experiencing an emergency or non-emergency condition just based on presenting symptoms.”

ACEP is encouraging members to use the 2020 Education and Operations Testing Period to educate hospital administrators on the emergency condition exception since, according to Davis, “many hospitals may not know about the exemption and still think that emergency physicians are required to comply in each individual case.” ACEP has even provided a sample letter {AUTOMATIC DOWNLOAD} which emergency physicians can use to communicate important AUC information with their hospital administrators.

What’s Next?

Though the AUC Program is not technically a preauthorization program, that’s where it’s leading. According to CMS, beginning in 2021 data will be collected from the program to be used to identify up to 5 percent of outlier ordering professionals who will then become subject to prior authorization requirements. According to Fierce Healthcare’s Joanne Finnegan, the outlier provider identification will start in 2023 at the earliest.

Specifically, CMS will use the following priority clinical areas to determine outliers:

  • 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

Learn More

To learn more about the AUC Program, check out the following resources:

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Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

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