Appropriate Use Compliance Deadline Delayed

Female doctor looking at patient in a CT scanner

October 20, 2021

Barbara Johnson, BSN, RN, CPC, FHFMA
Senior Revenue Cycle Consultant
PARA HealthCare Analytics, an HFRI Company

In 2019, the Centers for Medicare & Medicaid Services (CMS) announced that calendar year 2020 would serve as a “test and educate” period during which providers billing for advanced imaging studies are required to report whether the ordering physician consulted a clinical decision support mechanism. The requirement to report the informational codes is currently in effect, but Medicare will not yet impose penalties for failure to report, or for incorrect reporting. (The requirement does not apply to Critical Access Hospitals). The Appropriate Use Compliance (AUC) program was authorized by the Protecting Access to Medicare Act of 2014 (PAMA) to promote the use of AUC and decrease the number of inappropriate advanced diagnostic imaging services provided to Medicare beneficiaries.

Ordering physicians (or clinical staff acting at the physician’s direction) will consult the AUC using a clinical decision support mechanism (CDSM). The CDSM is an interactive, electronic tool that is either stand-alone or integrated into an electronic health record (EHR). When queried, it provides a response indicating that the advanced diagnostic imaging service is appropriate, not appropriate, or not applicable for the patient. The AUC requirements apply to advanced diagnostic imaging services (CT, PET, MRI, and Nuclear Medicine) provided in physician offices, hospital outpatient departments (including emergency departments), ambulatory surgical centers, and independent diagnostic testing facilities.

Consulting CDSMs exceptions

CMS released an MLN Matters article in July 2019 that includes the imaging HCPCS codes, the G-codes for the CDSMs, and AUC modifiers. There are a few exceptions to the requirement to consult the CDSM, which are:

  • Emergencies
  • Inpatient advanced diagnostic imaging services
  • Ordering physician meets hardship exception
    • Hardship exceptions include:
      • Insufficient internet access
      • EHR or CDSM vendor issues
      • Extreme and uncontrollable circumstances

If an exception exists, the physician will include it with the order and the furnishing physician will report the corresponding modifier on the claim.

AUC Requirements

After the physician has consulted the CDSM and ordered the advanced diagnostic imaging service, the following data will be sent, with the order, to the provider completing the imaging service:

  • The CDSM consulted by the ordering physician.
  • Whether the service adhered to the applicable AUC, did not adhere to the applicable AUC, or whether no criteria in the CDSM were applicable to the patient’s clinical scenario.
  • The National Provider Identifier (NPI) of the ordering physician. CMS maintains a list of qualified CDSMs on its website at Clinical Decision Support Mechanisms | CMS.

The following list was posted on August 30, 2021:

Mechanism Name Code
eviCore healthcare’s Clinical Decision Support Mechanism G1001
MedCurrent OrderWiseTM G1002
Medicalis Clinical Decision Support Mechanism G1003
National Decision Support Company CareSelectTM* G1004
AIM Specialty Health ProviderPortal®* G1007
Cranberry Peak exCDS G1008
Sage Health Management Soluntions Inc RadWise® G1009
Stanson Health’s Stanson CDS G1010
Radrite* G1011
AgileMD’s Clinical Decision Support Mechanism G1012
EvidenceCare’s Imaging Advisor G1013
InveniQA’s Semantic Answers in MedicineTM G1014
Reliant Medical Group SCSM G1015
Speed of Care CDSM G1016
HealthHelp’s Clinical Decision Support Mechanism G1017
LogicNets AUC Solution G1019
Curbside Clinical Augmented Workflow G1020
E*HealthLine Clinical Decision Support Mechanism G1021
Intermountain Clinical Decision Support Mechanism G1022
Persivia Clinical Decision Support G1023

New Advanced Diagnostic Imaging HCPCS Modifiers

Medicare also released eight new modifiers to be appended to the imaging HCPCS when an advanced diagnostic imaging is billed. The modifiers indicate the clinician’s use (or non-use) and compliance with a CDSM when ordering advanced diagnostic images.

Modifiers to be appended to Advanced Diagnostic Imaging HCPCS on Medicare Outpatient Claims

Modifier Short Descriptor Long Descriptor
MA Emer med cond susp/confirm 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 AUC hardship, insuf internet Ordering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of insufficient internet access
MC AUC hardship, vendor issues 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 AUC hardship, extreme circ Ordering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of extreme and uncomfortable circumstances
ME Order adheres to AUC The order for this service adheres to the appropriate use criteria in the clinical decision support mechanism consulted by the ordering professional
MF Order does not adhere to AUC The order for this service does not adhere to the appropriate use criteria in the clinical decision support mechanism consulted by the ordering professional
MG AUC not applicable to order The order for this service does not have applicable appropriate use criteria in the qualified clinical decision support mechanism consulted by the ordering professional
MH AUC consult not provided Unknown if ordering professional consulted a clinical decision support mechanism for this service, related information was not provided to the furnishing professional or provider

The excerpt below illustrates the mandatory reporting for a CT of the head billed to Medicare on a UB04:
a data table in medical billing software

AUC workflow requirements

The following is the workflow for meeting the AUC requirements:

  • The physician sees a Medicare beneficiary and plans to order an advanced diagnostic imaging service
  • The physician (or clinical staff under the direction of the physician) consults the AUC for the proposed advanced diagnostic imaging service through a CDSM. The CDSM can be integrated into the EHR or a separate portal
    • If a hardship exception exists, the physician will include it with the order
  • The CDSM will search for and present the AUC relevant to the patient’s condition
  • The CDSM response will indicate if the proposed advanced diagnostic imaging service:
    • adheres to the AUC, or
    • does not adhere to the AUC, or
    • if there is no applicable AUC
  • If it adheres to the AUC, the physician will proceed with the order
  • If it does not adhere, the physician must decide to order a different imaging service or proceed with the proposed service despite it not adhering to the AUC
  • The physician orders the advanced diagnostic imaging service and includes with the order:
    • the CDSM queried, and
    • the AUC response, and
    • the physician’s NPI
  • The rendering provider furnishes the imaging service to the patient
  • The rendering provider reports in the professional and institutional claims:
    • HCPCSG-code associated with the CDSM, and
    • The applicable AUC modifier, and
    • the ordering physician’s NPI

Analysis of ordering physician practices

The outcome of this program will be to analyze the ordering practices of the physicians and determine any outliers. PAMA calls for identification on an annual basis of no more than five percent of the total number of ordering physicians who are outliers. The use of two years of data is required for this analysis. Data collected during the education and testing period will not be used when identifying outliers. Outliers will be determined based on low adherence to applicable AUC or comparison to other ordering physicians. Physicians who are found to be outliers will be required to complete prior authorizations for advanced diagnostic imaging services.

The following clinical areas will be the focus of the analysis of outliers:

  • 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

Compliance Assistance

Healthcare Financial Resources and its division, PARA Healthcare Analytics (PARA), can provide compliance assistance to help you navigate the Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging regulation.

PARA is a revenue cycle solutions provider that offers price transparency, reimbursement, revenue integrity/coding, and compliance support. Comprised of seasoned professionals and equipped with a web-based cloud computing engine, the PARA Data Editor (PDE), they analyze, identify, repair, and improve the revenue cycle processes to support Providers in achieving their financial goals.

PARA is comprised of a team of coders, compliance experts, financial analysts, and IT professionals with extensive experience in focused disciplines to support the revenue cycle process. In fact, on average, our consultants have over 21 years of healthcare experience, allowing them to support clients with experience from the trenches. PARA’s services range from a web-based revenue cycle tool to a comprehensive revenue integrity program complete with a chargemaster audit, pricing services, monthly department meetings, and ongoing pricing, coding, reimbursement, and compliance support.

Contact us to learn more about how we can help you navigate today’s healthcare compliance concerns including the Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging regulation and more.

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