Updates for the AUC Program

In the 2019 Medicare Physician Fee Schedule (MPFS) Final Rule, the Centers for Medicare and Medicaid Services (CMS) provided updated guidance for the Appropriate Use Criteria Program.

Background

Mandated by Congress as part of the Protecting Access to Medicare Act (PAMA) of 2014, the Appropriate Use Criteria (AUC) Program is intended to reduce inappropriate use of advanced imaging exams. The program covers CT, MR,

Program Changes and Updates

In the Final Rule, CMS reaffirmed the mandatory January 1, 2020 implementation date. The first year will be an “educational and operations testing period” with a go live date of January 1, 2021. CMS will develop a series of HCPCS Level II G codes and modifiers during the 2020 rulemaking cycle to be used on claims in order to meet the aforementioned timeline. CMS will continue to pay claims regardless of whether this information is completely accurate on the claims.

CMS continues to consider future opportunities to use a unique claim identifier (UCI) number, but they have not committed to a timeline to transition to the use of UCIs. The benefit of using a UCI is that this information would come directly from the Clinical Decision Support Mechanism (CDSM) rather than potentially having manual intervention to assign G codes and modifiers. CMS has not indicated how long the G code with modifier approach to claims-based reporting will be utilized.

During the initial testing period, ordering professionals will consult AUC through a qualified CDSM. Furnishing providers will report corresponding G-codes and modifiers on their facility and physician claims. The most recent list of qualified CDSMs is available on the CMS website: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/CDSM.html

CMS added independent diagnostic testing facilities (IDTFs) to the list of applicable settings which also includes physician offices, hospital outpatient departments (including emergency departments), and ambulatory surgical centers. Because services provided in an IDTF require physician supervision and written orders must be furnished, CMS considered IDTFs to be a provider-led outpatient setting, and thus, appropriate to be added to the list. CMS also believes adding IDTFs to the list will ensure consistency of the AUC Program across all outpatient settings where advanced diagnostic imaging is provided.

CMS also finalized that ordering professionals experiencing internet issues, EHR or CDSM vendor issues, or extreme and uncontrollable circumstances (including natural and manmade disasters) will not be required to consult the AUC using a qualified CDSM, and the AUC consultation information would not be required to be listed on the claim. These circumstances will be self-attested at the time of placing the order. The claim submitted by the rendering provider and facility would report the necessary HCPCS Level II modifier to reflect the hardship self-attestation.

CMS also clarified that if the referring physician does not personally perform the consultation, then “when delegated by the ordering professional, clinical staff under the direction of the ordering professional may perform the AUC consultation with a qualified clinical decision support mechanism.” The ordering physician is still responsible for the consultation, since his or her NPI is reported on the claim. It is also the ordering physician who would be identified as an outlier and be subject to prior authorization requirements based on ordering patterns. While CMS has not clarified where on the UB-04/CMS1450 claim form the ordering physician’s NPI should appear, they have acknowledged that they need to identify where it should be reported.

For more information on the AUC program, see the CMS website: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/index.html

- Article by Coding Strategies® Staff