Diving Deeper into the AUC Program

In the last issue of RCC Update, we discussed the changes to the Appropriate Use Criteria Program made by the Centers for Medicare and Medicaid Services (CMS). In this issue, we will dive deeper into the program and how it impacts coding. To read the article from the last issue, please refer to the RCC Update archives: http://www.rccb.org/RCCB/Resources/Winter_2019/Updates_for_the_AUC_Program.aspx

Background

The Appropriate Use Criteria (AUC) Program is intended to reduce inappropriate use of advanced imaging exams. It was mandated by Congress as part of the Protecting Access to Medicare Act (PAMA) of 2014. The PAMA requirements apply to advanced imaging exams (CT, MR, and nuclear medicine, including PET) paid under the Medicare Physician Fee Schedule (MPFS), the Hospital Outpatient Prospective Payment System (OPPS), or the Ambulatory Surgical Center (ASC) Payment System.

AUC are designed to assist clinicians in selecting the most appropriate imaging study for a patient with a specific diagnosis or symptom. CMS can only approve AUC that are developed and endorsed by provider-led entities (PLE) such as national professional medical specialty societies. Once a PLE is qualified, all AUC developed or endorsed by that PLE are considered to be “specified AUC” for purposes of PAMA requirements. A current list of qualified PLEs can be found at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/PLE.html

The ordering physician, practitioner or clinical staff as delegated by the ordering professional and under their direction will access AUC through a qualified clinical decision support mechanism (CDSM). The CDSM is an electronic portal such as a module in an EHR or a web-based system. The patient’s information will either be pulled from the EHR or entered by the ordering professional into the CDSM, and the CDSM will provide feedback on the appropriateness of the proposed imaging exam. A current list of qualified CDSMs can be found at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/CDSM.html

Consultation

Radiologists are not excepted from the AUC consultation requirements and will be required to consult the AUC for advanced imaging studies they wish to order for patients they are treating.

Ordering professionals must communicate the results of the AUC consultation to the imaging provider, including the imaging facility and the interpreting radiologist. Both the facility and the radiologist must include AUC consultation information on Medicare claims, including which CDSM was used and whether the study was deemed appropriate. While it is the ordering professional’s responsibility to consult AUC, it is the furnishing professional who is responsible for reporting this information on the claim (facility and physician).

G Codes and Modifiers

Voluntary reporting began on July 1, 2018 and will continue through December 31, 2019. During this time, modifier QQ (Ordering professional consulted a qualified clinical decision support mechanism for this service and the related data was provided to the furnishing professional) may be applied to the CPT® code for the imaging service to identify the AUC consultation occurred. For more information on the use of modifier QQ, refer to MLN Matters MM10481.

During the 2020 rulemaking cycle, CMS will develop a series of G codes and modifiers that must be used on claims during the testing period. Ultimately, the G codes will identify the CDSM being used, and the modifiers will identify AUC adherence.

CMS proposes each CDSM would be assigned a G code whose description would contain the name of the CDSM. If multiple advanced diagnostic imaging services are reported on the claim, CMS could link the single G code to all of the applicable imaging services on that claim. This would be appropriate only if each AUC consultation for each service on the claim was through the same CDSM.

In the scenario that different CDSMs are used for different services on the claim, then multiple G codes would be needed. Each G code would appear as a separate line item on the claim. It would then not be possible to link the CDSM to the service for which it was used.

CMS proposes to use modifiers that would appear on the same line as the CPT® code for the imaging. Three modifiers would be developed to report the result of the consultation as:

  1. Imaging service adheres to the applicable AUC
  2. Imaging service does not adhere to the applicable AUC
  3. AUC were not applicable for the imaging service

With these modifiers appended to the imaging CPT® codes, Medicare would more easily be able to link the AUC adherence information with the imaging service.

CMS will release more information on the G codes and modifiers as they are finalized.

Reporting Concerns

One of the biggest concerns in reporting the AUC information surrounds the requirement of the ordering professional to perform consultation and provide the furnishing professional the information to be reported on the claim. Commenters in the CY 2019 MFPS Final Rule noted this poses questions on who bears responsibility during an audit if the information is not available. CMS “will take into account the specific roles of ordering and furnishing professionals and facilities as the program develops and [CMS begins] to engage in program monitoring activities.”

Qualified CDSMs much generate and provide a certification or documentation that includes the CDSM used, the name and NPI of the ordering professional, and information on AUC adherence. In the CY 2019 MFPS Final Rule, some commenters noted concern regarding the lack of clarification of whether the CDSM certification or documentation would include the appropriate G codes and modifiers. The clarification was requested because “(1) Each qualified CDSM will know its G-code and can readily convert their adherence rating system into modifiers, (2) the required data could be transmitted between EHR and CDSM vendors and communicated between professionals in a standardized manner, and (3) accuracy of consultation reporting would improve.” CMS agrees and expects to see CDSMs include the G codes and modifiers as they become available in their certification or documentation. However, if they do not see the adjustment, CMS will consider making it a requirement.

Please see the following resources for more information on AUC/CDS:

MLN Fact Sheet: Appropriate Use Criteria for Advanced Diagnostic Imaging

CMS Appropriate Use Criteria Program

CY 2019 Medicare Physician Fee Schedule Final Rule

ACR Detailed Summary of the Appropriate Use Criteria Provisions of the 2019 Medicare Physician Fee Schedule Final Rule

- Article by Coding Strategies® Staff