It’s a cold January here in the northeastern US, so it’s a good time to heat up plans to comply with the Medicare AUC Mandate!  We have entered the official Educational and Operations Testing Period of 2020, which means that Medicare is ready to accept the Appropriate Use Criteria (AUC) modifiers and G-codes on claims now being submitted.  Let’s first review what this Medicare mandate means and then make plans to get it operational in your practice.

It all began with the Protecting Access to Medicare Act of 2014 that requires referring providers to consult appropriate use criteria (AUC) via a qualified clinical decision support mechanism (CDSM) that is approved by the Centers for Medicare and Medicaid Services (CMS), prior to ordering CT, MR, nuclear medicine and PET exams for outpatients covered by Medicare Part B.  If the AUC consultation is not done by the ordering physician, or if the proper codes are not reported to Medicare by the radiologist, then payment to the radiologist will be denied.  

This first year of the program (2020) is an “educational and operations testing period”, with no Medicare penalties to rendering physicians for failure to report or for incorrect reporting of AUC consultation information on claims.  Beginning in 2021, rendering providers will not receive Medicare technical or professional component payment for the procedure without a correctly documented AUC consult.  CMS has published a claims guidance document in MLN Matters (MM11268 Rev. 1/1/20)  that includes a full list of the procedures affected, the modifiers to be added, and the G-codes that describe which system is used.

Services that are Subject to AUC Consultation

This rule will apply for outpatient imaging services whether the imaging services are performed in the hospital outpatient department, hospital emergency department, radiology office or imaging center, ambulatory surgery center, or in an Independent Diagnostic Testing Facility (IDTF). 

There are a few exceptions to the requirement that an AUC consultation take place in order for the claim to be paid:

• Inpatient services covered under Medicare Part A are not subject to the regulation.
  
  
• Services performed at a Critical Access Hospital (CAH) are not subject to the regulation.
  
  
• Services ordered for an individual with an emergency medical condition^[i] do not require a consultation, regardless of the location where those services are performed. The ordering physician’s determination of an emergency condition will govern.
  
  
• No AUC consultation is required when certain hardship circumstances exist for the ordering professional. These include:
  
  
  • Insufficient internet access.
  • Electronic health records (EHR) or qualified clinical decision support mechanism (CDSM) vendor issues. For example, issues might include technical problems, installation or upgrades that temporarily impede access to CDSMs, a vendor ceases operation or a CDSM becomes de-qualified.
  • Extreme or uncontrollable circumstances (including natural or manmade disasters).

In addition to these exceptions, no AUC consultation and reporting will be required by Medicare Advantage plans (Part C) or when Medicare is a secondary payer unless the primary payer has such a requirement.  In cases where the radiologist adjusts the exam, such as to add contrast to a non-contrast order, it is not necessary for him or her to consult a CDSM; the original consultation by the ordering physician is sufficient. 

Performing and Reporting the AUC Consultation

The AUC consultation must take place using a qualified Clinical Decision Support Mechanism (CDSM).  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.

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

• the NPI of the ordering professional who consulted the AUC (if different from the furnishing professional). Note that the ordering professional’s clinical staff may perform the AUC consultation when delegated to do so under the direction of the ordering professional.
  
  
• whether the service ordered would or would not adhere to specified applicable AUC, or whether the specified applicable AUC consulted was not applicable to the service ordered. This is indicated by a modifier added to the procedure code for the service being billed. 
  
  
• which qualified CDSM was consulted by the ordering professional. CMS has posted the list of qualified CDSMs on its website along with the HCPCS “G-code” that is to be reported. 

A modifier will be attached to the relevant procedure code to describe either the level of adherence to AUC or an exception to the program.  Modifiers MA, MB, MC and MD denote exceptions to the use of a CDSM, and payment will not be denied when one of these conditions exists.  Although CDSM consultation is not required at either a Critical Access Hospital (CAH) or at a Federally Qualified Health Center (FQHC), no modifier has been defined to claim an exemption for services provided in such facilities when the interpretation is performed elsewhere. 

When a CDSM has been consulted and modifier ME, MF or MG is indicated, then a G-code will be reported on a separate line to identify the CDSM that was used.  CMS notes that multiple G-codes may appear on a single claim, when appropriate. 

The reporting rules can be summarized using this table:

How to Prepare

Ordering physicians are now beginning to hear about the AUC mandate but they might be less than fully informed about it.  Radiology groups can use the 2020 testing year to gather data on their ordering practices and provide targeted marketing toward the high-volume groups. 

Referring practices that use an EHR might have a CDSM already available, but the radiology group can help determine if it is CMS-qualified.  In some instances, radiology groups will work with ordering practices by providing a portal to the hospital or radiology facility's CDSM or provide information about free online products where these referrers can consult with AUC and provide the information on their orders.

The American College of Radiology (ACR) has good information for practices on their  Clinical Decision Support web page or in their AUC Toolkit.  Another resource is the MGMA Toolkit that contains actions steps from the ordering physician’s perspective. 

Adherence to AUC Might Avoid Future Prior-Authorization

Once the AUC data begins to be collected by CMS in 2021 it will be used to identify “outlier ordering professionals”.  Outliers will face a requirement to obtain prior authorization before ordering certain procedures at some future date.  While the details of the outlier calculations and timing of the prior authorization requirement are not yet known, the following priority clinical areas have been identified by CMS:

• Coronary Artery Disease (suspected or diagnosed)
• Suspected pulmonary embolism
• Headache (traumatic and 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

Pointing out this potential prior authorization requirement to referring providers might help radiologists enlist their cooperation in the use of AUC.  It has been pointed out that disagreement between the ordering physician and the AUC result is not a “hard stop” to ordering whereas denial of authorization for the procedure would make their lives more difficult and delay patient care.

Conclusion

It is always possible that full implementation of the AUC/CDS requirement will be delayed, much as the implementation of ICD-10 coding was delayed, but eventually the penalty phase will begin.  There will also be additional clarification of the rule as time goes on.  Practices can use this preliminary period to be sure they are in the best position possible to gather and report the required AUC data and avoid losing reimbursement.  Make sure you subscribe to this  blog to receive updates on this topic and many others related to radiology revenue cycle management. 

[i] An “emergency medical condition” is defined under the Emergency Medical Treatment And Labor Act (EMTALA) as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.  In addition, with respect to a pregnant woman who is having contractions, an emergency medical condition exists when there is inadequate time to effect a safe transfer to another hospital before delivery, or that transfer may pose a threat to the health or safety of the woman or the unborn child.

Sandy Coffta is the Vice President of Client Services at Healthcare Administrative Partners.

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