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AUC - Frequently Asked Questions

AUC - Frequently Asked Questions

(Updated 11/1/2019)

What does AUC stand for?
AUC stands for “Appropriate Use Criteria” which is the name of the overall policy and program. 

What does CDSM stand for?
CDSM stands for “Clinical Decision Support Mechanism” and qCDSM stands for qualified CDSMs.

Where can I find a list of qCDSMs?
CMS maintains a list of qCDSMs, 
click here to view the list.

What is the difference between AUC and CDSM?
While sometimes the terms are used interchangeably, Appropriate Use Criteria is both the name for the overall policy and the name for the specific sets of criteria ordering clinicians need to consult through the Clinical Decision Support Mechanism. 

The Clinical Decision Support Mechanisms are the portals through which the ordering clinician accesses the appropriate use criteria programs. Ordering professionals must use “qualified” Clinical Decision Support Mechanisms (qCDSMs) for the purposes of this policy.

What is a provider-led entity (PLE)?
Provider-led entities maintain the sets of Appropriate Use Criteria that are accessed through the qCDSM for the purposes of the AUC program. Per the name, they must be led by providers and their job is to ensure that their Appropriate Use Criteria reflects their clinical consensus on the appropriate uses of advanced imaging. 

A list of PLEs is maintained by CMS, 
click here to view the list.

Why does the AUC policy matter for imaging centers?
If you perform any outpatient advanced imaging for Medicare patients, you will need to comply with this policy in order to get that claim reimbursed. 

When does the AUC program begin?
The voluntary reporting period has already begun (started in July 2018). The voluntary reporting period allowed claims to include the modifier “QQ” to certify that the ordering professional consulted AUC through a qCDSM.

The “educational and operational testing period” begins on January 1, 2020. Full implementation begins on January 1, 2021.

Reference: 
https://www.federalregister.gov/d/2018-24170/p-2157

What does the educational and operational testing period entail?
The educational and operational testing period begins January 1, 2020 and will last one year. CMS has indicated that ordering clinicians must consult AUC through a CDSM, but that claims will not be denied if there is incorrect AUC information.

What exactly the expectations are during the educational and operational testing period remains one of the most important points of clarification we still need to get from CMS. Does this mean that claims with NO AUC information will still be paid, or does CMS expects some AUC information on each claim and will simply not deny the claim if that information is incorrect?

We expect CMS to clarify their expectations through guidance in the summer of 2019. 

Reference: 
https://www.federalregister.gov/d/2018-24170/p-2157 

UPDATE: CMS has clarified that for CY 2020, applicable imaging claims with no AUC-related information will not be denied.

From CMS:
"During CY 2020, CMS expects ordering professionals to begin consulting qualified CDSMs and providing information to the furnishing practitioners and providers for reporting on their claims. Situations in which furnishing practitioners and providers do not receive AUC-related information from the ordering professional can be reported by modifier MH. Even though claims will not be denied during this Educational and Operations Testing Period, inclusion is encouraged."

Reference: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11268.pdf


How will this program affect my department or center?
Your imaging departments and centers will need to pass along AUC information from the ordering professional to your billing professionals in order if you want these Medicare claims to be reimbursed. 

When does the AUC policy apply?
The AUC policy applies to all Medicare advanced imaging performed in an applicable site through an applicable payment system. 

The Secretary of Health and Human Services may add additional applicable settings in the future, but as of today the applicable settings include:
• Clinician office
• hospital outpatient department (including emergency departments)
• Ambulatory Surgical Center
• Independent Diagnostic Testing Facility

Applicable payment systems include: 
• Physician Fee Schedule (PFS)
• Hospital Outpatient Prospective Payment System (HOPPS)
• Ambulatory Surgical Center (ASC) payment system

Reference: 
https://www.federalregister.gov/d/2018-24170/p-2173 
Reference: 
https://www.federalregister.gov/d/2018-24170/p-2205 

What is an “advanced” image?
Full definition can be found in the Social Security Act at 1834(e)(1)(B). 

Advanced imaging services include diagnostic magnetic resonance imaging, computed tomography, and nuclear medicine (including positron emission tomography). 

Reference: 
https://www.ssa.gov/OP_Home/ssact/title18/1834.htm

What are the exceptions or exemptions to the AUC policy?
Ordering professionals can claim exemptions to the AUC policy if:
1-the patient is deemed to be in an emergency medical condition
2-the ordering professional has a hardship exemption for any of the following reasons:
            -insufficient internet access
                        -EHR or CDSM vendor issues
                        -extreme and uncontrollable circumstances

If the ordering professional is claiming any of the above exceptions or exemptions this must be indicated via a modifier code on the claim.

Reference: 
https://www.federalregister.gov/d/2018-24170/p-2241

When can the emergency exception be claimed?
Ordering professionals may claim the emergency exemption if the patient is deemed to be in a “emergency medical condition.” This term is defined in the SSA 1867 (e)(1) as:

(A) 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—
   (i) 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,
   (ii) serious impairment to bodily functions, or
   (iii) serious dysfunction of any bodily organ or part; or
(B) with respect to a pregnant woman who is having contractions—
   (i) that there is inadequate time to effect a safe transfer to another hospital before delivery, or
   (ii) that transfer may pose a threat to the health or safety of the woman or the unborn child.

Reference: 
https://www.ssa.gov/OP_Home/ssact/title18/1867.htm

Does this apply to Critical Access Hospitals?
Critical Access Hospitals (CAHs) are not paid through an applicable payment system, nor are they considered an applicable site. Therefore, CAHs are exempt from the AUC program. 

Furthermore, radiologists who work outside the CAH, but are providing the professional component services of an applicable advanced image whose technical component was performed by the CAH are not subject to the AUC program. Therefore, even if the radiologist is billing on an applicable payment system, because the technical component was performed in the CAH, the radiologist would not have to report AUC information. The radiologist would need to indicate on his or her claim that there was an exemption through a to-be-created modifier code. 

Note: The modifier code to indicate that the TC of an applicable image was performed in a non-applicable setting has not been created as of 11/1/19. We are still asking CMS to clarify how this exemption would be reported on the PC of an imaging claim.

Is AUC applicable to the Professional Component, the Technical Component, or both?
The AUC information must be present on all applicable claims including professional component billing, technical component billing, and global billing. 

Reference: 
https://www.federalregister.gov/d/2018-24170/p-2206 

What information must be present on applicable claims?
There are three AUC data elements that must be included on every applicable claim.
            1-The NPI of the ordering professional
            2-The qCDSM used by the ordering professional
            3-Whether the image ordered adhered, did not adhere, or was not applicable to the AUC

How will we report the required information on applicable claims?
            1-The NPI of the ordering professional will go in a designated field
            2-The qCDSM will be indicated on the claim via a G-code on its own line
            3-The adhere, did not adhere, or not applicable result will be indicated via modifier on the same line as the advanced imaging HCPCs code.

Reference: 
https://www.federalregister.gov/d/2018-24170/p-2240
 

What G-codes can be used in 2019 to report qCDSM?

The following G-codes are used to report the qCDSM used by the ordering professional:

Appropriate Use Criteria G-Codes

G1000

Applied Pathways

G1001

eviCore

G1002

MedCurrent

G1003

Medicalis

G1004

National Decision Support Company

G1005

National Imaging Associates

G1006

Test Appropriate

G1007

AIM Specialty Health

G1008

Cranberry Peak

G1009

Sage Health Management Solutions

G1010

Stanson

G1011

Clinical Decision Support Mechanism, qualified tool not otherwise specified, as defined by the Medicare Appropriate Use Criteria Program

 

Reference: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11268.pdf

What modifier codes can be used to report the result of the AUC inquiry?

The following modifier codes are used to report the result of the AUC inquiry on the same line as the imaging CPT code. These modifier codes are also used to report the various exemptions to the AUC reporting requirement.

Appropriate Use Criteria Modifier Codes

MA

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

Ordering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of insufficient internet access

MC

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

Ordering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of extreme and uncontrollable circumstances

ME

The order for this service adheres to the appropriate use criteria in the clinical decision support mechanism consulted by the ordering professional

MF

The order for this service does not adhere to the appropriate use criteria in the qualified clinical decision support mechanism consulted by the ordering professional

MG

The order for this service does not have appropriate use criteria in the clinical decision support mechanism consulted by the ordering professional

MH

Unknown if ordering professional consulted a clinical decision support mechanism for this service, related information was not provided to the furnishing professional or provider

QQ

Ordering professional consulted a qualified clinical decision support mechanism for this service and the related data was provided to the furnishing professional (effective date: 7/1/18)


Reference:
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11268.pdf

Will Medicare still pay if the ordering professional orders an image that does not adhere to the AUC?
Yes. Medicare will still pay the claim even if the result of the AUC consultation is not adhere. Eventually, ordering clinicians who have the highest rates of non-adherence will be subject to a form a pre-authorization. Ordering clinicians will be evaluated based on the “clinical priority areas” and the exact details of which ordering professionals will be subject to pre-authorization and when they will be subject to pre-authorization are still to be determined by CMS. 

Reference: 
https://www.federalregister.gov/d/2018-24170/p-2274 

Can an imaging center use the qCDSM to find this information for the ordering professional?


No. The ordering professional must consult the AUC through a qCDSM themselves or have clinical staff under the direction of the ordering professional consult the AUC on their behalf.

The individual performing the consultation must have “sufficient clinical knowledge to interact with the CDSM and communicate with the ordering professional.”

Reference: 
https://www.federalregister.gov/d/2018-24170/p-2204

What aspects of this program still need to be clarified?


There are several aspects of the program that need to be clarified. These include:

 -Explaining how we are supposed to handle imaging claims that have multiple ordering professionals, potentially using multiple qCDSM systems.

-Clarifying how claims with more than 4 modifiers per line may be reported on the UB-04 claim form.

-CMS needs to create a modifier or another mechanism to allow radiologists to report that the technical component of an image was performed in a non-applicable setting.

-We are still awaiting specific instructions on reporting the NPI of the ordering professional on the paper and electronic UB-04 claim form.

Where can I get more information?
CMS link
AHRA infographic
Link to the relevant section of the 2019 Physician Fee Schedule Rule: 
click here 
Appropriate Use Criteria regulations ~ 42 CFR §414.94 Appropriate use criteria for advanced diagnostic imaging services: 
click here

MLN Matters - Appropriate Use Criteria for Advanced Diagnostic Imaging – Educational and Operations Testing Period – Claims Processing Requirements: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11268.pdf


 

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