January 1, 2020 marked the beginning of the one-year Educational and Operations Testing Period for the Appropriate Use Criteria (“AUC”) Program. The Protecting Access to Medicare Act (“PAMA”) requires referring clinicians to consult evidenced-based criteria prior to ordering advanced diagnostic imaging services for Medicare outpatients. Casting a wide net, this program is described as “massive”, impacting a vast number of clinicians across almost every medical specialty, including primary care who order advanced diagnostic imaging services such as computed tomography (“CT”), positron emission tomography (“PET”), nuclear medicine, and magnetic resonance imaging (“MRI”). Anticipated to be fully implemented January 2021, advanced imaging services may be denied if AUC information is not appended to claims.
Who must comply?
The AUC program imposes criteria on advanced diagnostic imaging services paid under the Medicare Physician Fee Schedule (“MPFS”), Outpatient Prospective Payment System (“OPPS”) or Ambulatory Surgical Center (“ASC”) Payment System furnished in the following settings:
Physician’s office
Hospital outpatient department (including the ED)
Ambulatory Surgery Center
Independent Diagnostic Testing Facility
Practitioners ordering advanced diagnostic imaging will be required to consult a qualified and evidence-based tool, communicating AUC-related information to the furnishing practitioner, who, in turn, reports corresponding data on their claims. The applicable setting is where the imaging is rendered, not the setting where the imaging service is ordered.
Consulting Clinical Decision Support Mechanism
The Clinical Decision Support Mechanism (“CDSM”) is the instrument by which AUC consultations are accomplished. AUC consultations are intended to assist clinicians in selecting the imaging study that is most likely to improve health outcomes based on a patient’s clinical presentation, linking a specific medical condition or symptoms with an assessment of the appropriateness of a given diagnostic service. Generally, criteria are developed by provider-led entities and must be approved by The Center for Medicare and Medicaid Services (“CMS”). The CDSM effectively becomes the guideline for a particular clinical scenario relative to appropriate testing, providing a determination of whether the order complies with AUC.
Assimilating the required consultations seamlessly into the clinical workflow will be vital. While standalone applications exist for direct entry of patient information, integration of CDSMs into the electronic health record (“EHR”) can effectively streamline the process of the AUC consult during the patient evaluation. Ideally, practitioners would interact directly with the CDSM through their EHR, optimizing workflow efficiency while facilitating communication of necessary information to furnishing providers.
Who can perform AUC consultations?
CMS finalized that ordering professionals have flexibility to delegate the task of the AUC consultation to clinical staff, acting under the direction of the ordering practitioner, to consult the CDSM. In this regard, there would be an expectation that clinical staff demonstrate competency and a working knowledge that facilitates effective communication with the ordering professional, as well as interaction with the AUC. The referring provider, however, is ultimately responsible for the order.
Once the AUC program is fully executed, PAMA calls for providers to be subject to prior authorization of advanced imaging services if they demonstrate patterns of non-compliant orders. Accordingly, communication between the staff rendering the AUC consult and the ordering professional is integral to appropriate referrals for these services, to include frequency of the diagnostic testing adherent to the AUC. The ordering physician has a vested interest in not only ensuring they are providing the appropriate testing for their patient, but also ensuring compliance with AUC to avoid becoming subject to future authorization requirements.
Proper Reporting
Effective January 2021, the AUC program will only allow for payment of advanced imaging services if the claim includes information about the ordering professional’s consultation of applicable AUC through a qualified CDSM. CMS has developed G-codes to identify the CDSM consulted and corresponding HCPCS modifiers to describe the level of adherence to AUC and/or an exception to the program which should accompany the diagnostic imaging claims. Providers rendering these services should note that claim-based reporting requires the consultation information when advanced diagnostic radiology services are reported globally, or on both the technical and professional components when billed separately.
The following modifiers have been established for placement by the rendering provider on the same line as the CPT code for the advanced diagnostic imaging service:
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;
QQ - Ordering professional consulted a qualified clinical decision support mechanism for this service and the related data was provided to the furnishing professional.
Claims that report HCPCS modifier ME, MF, or MG should additionally contain a G-code (on a separate claim line) to report the qualified CDSM was consulted:
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.
Testing Period
Claims processing systems will be poised to accept AUC claims’ information effective January 1, 2020. During this Educational and Operational Testing Period, claims from furnishing professionals will be processed and paid without this information; however, as clarified by CMS:
Though claims will be paid without AUC information or if information is misreported during this phase, incorporating CDSM consults into workflow and providing information to furnishing providers for reporting on their claims will be critical during this testing period in order to ensure compliance in 2021. This testing period affords ordering practitioners the opportunity to begin reporting without risk of claim denials. Furnishing providers are encouraged to report modifier -MH even if they do not receive AUC-related information from the ordering professional in this initial phase.
Exceptions and Hardships
Exceptions to consulting CDSMs involve situations in which the patient has an emergency medical condition. CT, MRI, Nuclear Medicine or PET Scans ordered for a hospital inpatient, and for which payment is made under Medicare Part A, are automatically exempt. CMS also finalized the following hardship criteria excusing ordering professionals from the AUC consult:
Insufficient internet access;
EHR or CDSM vendor issues;
Extreme and uncontrollable circumstances.
Ordering professionals experiencing a significant hardship may self-attest and include that information on the order for the advanced diagnostic imaging service. In turn, the furnishing provider would then append the corresponding modifier to their claim identifying the ordering professional’s hardship category.
The following modifiers have been established specifically for exceptions and/or hardships:
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;
Prior Authorization Requirements
Looking ahead, practitioners whose ordering patterns are considered outliers will be subject to prior authorization. Future rulemaking will offer methodology surrounding outlier identification and requirements for prior authorization. In the interim, CMS has clarified that data from the testing period will not be used to develop outlier methodology. While detail on outlier methodology and prior authorizatio is not yet available, an initial list of priority clinical areas was identified in the CY 2017 MPFS Final Rule:
Coronary artery disease (suspected or diagnosed)
Suspected pulmonary embolism
Headache (traumatic or non-traumatic)
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
Mitigate Future Denials
Claims for advanced diagnostic imaging that fail to append AUC consultation information will be denied effective January 2021. By initiating the process of integrating consultations and reporting into the work flow now, providers can mitigate denials when the program is fully executed.