HAP Radiology Billing and Coding Blog

New Information on the Medicare Rules for Appropriate Use Criteria and Clinical Decision Support

Posted: By HAP USA on July 24, 2017

New Information On The Medicare Rules For AUC CDS heatlhcare administrative partnersNew information has been provided by The Centers for Medicare and Medicaid Services (CMS) that will supplement our article An Update for Radiologists on Appropriate Use Criteria and Clinical Decision Support.  We can now update you from the recent release of the “Proposed Medicare Physician Fee Schedule (MPFS) for 2018” and the “Proposed Rule for Quality Payment Program Year 2.”

Requirement to Use AUC / CDS Delayed

The MPFS proposed rule for 2018 delays the start of the requirement for ordering physicians to consult Appropriate Use Criteria (AUC) using a qualified Clinical Decision Support Mechanism (CDSM) until January 1, 2019. The initial year of 2019 will be “an educational and testing year” according to Medicare, during which radiologists will continue to receive full reimbursement regardless of whether their claims contain the information about the required AUC consultation.  A voluntary reporting period is expected to be available beginning around July 2018 that will allow practices to test their systems and become familiar with the operation of the program.

Qualified Clinical Decision Support Mechanisms (CDSM)

As expected, CMS has posted the list of qualified CDSMs on its website.  The list includes:

  • Applied Pathways CURION™ Platform
  • Cranberry Peak ezCDS 
  • eviCore healthcare's Clinical Decision Support Mechanism
  • National Decision Support Company CareSelect™
  • National Imaging Associates RadMD
  • Sage Health Management Solutions Inc. RadWise®
  • Test Appropriate CDSM

An additional 9 CDSMs are listed as having ‘preliminary’ qualification. A CDSM is defined as, “an interactive, electronic tool for use by clinicians that communicates AUC information to the user and assists them in making the most appropriate treatment decision for a patient’s specific clinical condition.”  The CDSM tool can be either an integral part of an existing electronic health records system or a stand-alone system, as long as it is certified by CMS as a qualified system.

Claims Reporting Instructions

Radiologists will have to include certain information on their Medicare claim forms to let CMS know whether the requirements have been fulfilled or not. The information to be reported is:

  • which qualified CDSM was consulted by the ordering professional;
  • whether the service ordered would or would not adhere to specified applicable AUC, or whether specified applicable AUC were not applicable to the service ordered; and
  • the NPI of the ordering professional (if different from the furnishing professional).

The MPFS proposes to implement this reporting requirement using a series of G-codes that would describe the specific CDSM that was used by the ordering professional, with one code being defined for each CDSM and one for use with a newly-qualified CDSM that has not yet been issued its own code. Another G-code will be used when no AUC consultation took place. 


In addition to the G-codes, a series of modifiers will describe whether the imaging service ordered would adhere to the applicable AUC criteria or not, or if such criteria were not applicable to the imaging service ordered. Modifiers will also be developed to describe exceptions to the rules, such as for an emergency medical condition or a significant hardship.

AUC / CDS Can Be Used For MIPS Credit

The “Proposed Rule for Quality Payment Program (QPP) Year 2” published June 30, 2017 establishes a direct tie between the Medicare Incentive Based Payment System (MIPS) and the AUC program under the MPFS. The QPP rule will give MIPS credit to ordering professionals for consulting AUC using a qualified CDSM beginning January 1, 2018.  The “Patient Safety and Practice Assessment” subcategory of MIPS Improvement Activities for 2018 will include such consultation as a high-weighted activity for the Advancing Care Information (ACI) Bonus.

Background on AUC / CDS

The Medicare regulation was enacted as part of the Protecting Access to Medicare Act (PAMA) of 2014. It mandates that ordering providers consult AUC when ordering advanced imaging examinations such as MR, CT, PET and other nuclear medicine exams for Medicare patients.   The burden of reporting the CDSM consultation is on the radiologist, whose payment will be denied in full when the ordering provider fails to use the system. 


The denial of payment will apply to both the professional and technical components of the Medicare reimbursement, whether the procedure is billed separately or globally. This brings the interests of the radiology group and the hospital into alignment to jointly implement and develop a system with which ordering physicians must comply.  There is no financial penalty to the ordering physician who does not consult and document the use of AUC.


The rule requiring consultation with AUC will apply for outpatient services whether in the hospital or the imaging center. Inpatient services covered under Medicare Part A are not subject to the regulation, nor are services ordered for an individual with an “emergency medical condition” regardless of the location where those services are performed.  

Stay Up To Date on the Latest Rules

Healthcare Administrative Partners will continue to provide updated information on this new Medicare requirement as it becomes available.   Subscribe to this blog for the latest developments.


Related Articles:

An Update for Radiologists on Appropriate Use Criteria and Clinical Decision Support

Pros and Cons of Utilizing Teleradiology Services

Best Practices in Radiology Patient Billing

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Topics: radiology reimbursement, clinical decision support, radiology, appropriate use criteria

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