AUC - Frequently Asked Questions

AUC Update as of March 2023

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.

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 professionals need to consult through a Clinical Decision Support Mechanism. 

The Clinical Decision Support Mechanisms are the electronic tools through which the ordering professional accesses the appropriate use criteria content. Ordering professionals must use “qualified” Clinical Decision Support Mechanisms (qCDSMs) approved by CMS for this policy.

What is a provider-led entity (PLE)?
Provider-led entities maintain the sets of Appropriate Use Criteria that are accessed through the qCDSMs for 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. 

CMS maintains a list of PLEs, click here to view the list.

What is an “advanced” image?
The 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 G-codes can be used to report qCDSMs?

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

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 consultation?

The following modifier codes are used to report the result of the AUC consultation on the same line as the imaging CPT^® code. In addition, these modifier codes are used to report the various exemptions to the AUC reporting requirement.

**Note: The QQ and MH modifiers will be discontinued once the penalty phase commences. A new modifier will be established to identify claims for services where it is not required to consult AUC and the established modifiers do not apply. (Reference: https://www.federalregister.gov/d/2021-23972/p-2278)

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

Policy

Why does the AUC policy matter for imaging centers?
If you perform any outpatient advanced imaging for Medicare patients (Technical, Professional or Global), you will need to comply with this policy in order to receive payment for advanced imaging services when the penalty phase goes into effect.

When does the AUC program begin?
Full implementation, also known as the “penalty phase,” is currently scheduled for January 1, 2023, or the first January of the year following the end of the COVID-19 Public Health Emergency.

We are currently still in the “educational and operational testing period” which began on January 1, 2020.
Reference:  https://www.federalregister.gov/d/2021-23972/p-2144

What does the educational and operational testing period entail?
The educational and operational testing period began on January 1, 2020. CMS has indicated that ordering professionals must consult AUC through a CDSM, but claims will not be denied if there is missing or incorrect AUC information.

CMS has clarified that during the education and operational testing period, applicable imaging claims without 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.”

Note: This initial testing period was extended through 2022 per the MPFS 2022 Final Rule.

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

Under what circumstances does the AUC policy apply?

The AUC policy applies to all advanced imaging performed in an applicable site through an applicable payment system for Medicare patients. 

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

Applicable payment systems include: 
• Medicare Physician Fee Schedule (MPFS)
• 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 are the exceptions or exemptions to the AUC policy?

Ordering professionals can claim exemptions to the AUC policy if a service is:

• Ordered for an inpatient
• A suspected or confirmed emergency medical condition
• Situations of serious hardship

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

Are hospitals that participate in the Maryland Total Cost for Care Model subjected to the AUC policy?

No.

Outpatient departments of hospitals in Maryland that participate in the Maryland Total Cost of Care Model are not subject to the AUC program because imaging services are not paid under an applicable payment system.

CMS identifies institutional claims from a hospital paid under the Hospital Payment Program within the Maryland Total Cost of Care Model based on their CMS Certification Number (CCN), and the claims bypass AUC processing edits.

CMS will use box 32 on the professional claim to identify that the TC of the image was performed in a hospital that is paid under the Hospital Payment Program within the Maryland Total Cost of Care Model.

Reference: https://www.federalregister.gov/d/2021-23972/p-2227

What if a patient’s hospital inpatient status is changed to outpatient?

If a patient is in inpatient status when the advanced diagnostic imaging services were ordered and furnished, AUC requirements would not apply because the patient would not be receiving care in an applicable payment system or applicable payment setting.

In order to properly exempt these claims, CMS finalized a proposal to allow institutional claims with condition code 44 to be exempt from AUC Claims processing edits. CMS expects less than half of one percent of claims to include condition code 44.

Reference: https://www.federalregister.gov/d/2021-23972/p-2233

Does the AUC requirement apply if Medicare is the patient’s secondary payer?

No.

According to CMS, Medicare is listed as a secondary payer for 1.5% of advanced diagnostic imaging services that apply to the AUC program.

In 2022, CMS finalized a policy to allow claims identifying Medicare as the secondary payer (using block 1 or the electronic equivalent of the practitioner claims and using FL 50/51 or the electronic equivalent of institutional claims) to bypass AUC program claims processing edits.

Reference: https://www.federalregister.gov/d/2021-23972/p-2251

When can the emergency exception be claimed?

Ordering professionals may claim the emergency exemption if the patient has a suspected or confirmed “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 or considered an applicable site. Therefore, CAHs are exempt from the AUC program. 

Furthermore, radiologists who work outside the CAH but provide 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, the radiologist would not have to report AUC information because the technical component was performed in the CAH. The radiologist would need to indicate on his or her claim that there was an exemption through a to-be-created modifier code. 

Note: CMS finalized a policy that advanced imaging services performed when the TC is not furnished in an applicable setting not be subjected to the AUC program. A modifier will be used to identify practitioner claims that are not subjected to the AUC program. (Reference: https://www.federalregister.gov/d/2021-23972/p-2225)

Does AUC apply to rural health clinics?

Clinicians including Physicians, Nurse Practitioners, Physician Assistants who work in Rural health clinics (RHCs) would need to comply with the Appropriate Use Criteria mandate as ordering professionals.

However, if the advanced imaging is performed in the RHC, the RHC would be exempt from the AUC mandate as furnishing professionals because they are not paid through an applicable payment system. While technically possible, it is our understanding that providing the technical component of an advanced imaging service in an RHC setting is very uncommon.

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 two AUC data elements that must be included on every applicable claim and one additional data element that is required if a consultation was performed.

Required:

• The NPI of the ordering professional
• A modifier that indicates the results of the consultation, or why a consultation was not required

Required if consultation performed:

• The G code for the consulted qCDSM used by the ordering professional

 How will we report the required information on applicable claims?

1. The NPI of the ordering professional will go in a designated field (see https://www.cms.gov/files/document/se20002.pdf for more detail)
   
   
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 status will be indicated via modifier appended to the advanced imaging CPT^®/HCPCS code.

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

How are multiple ordering professionals represented on a claim?

The 2022 Medicare Physician Fee Schedule (MPFS) Final Rule confirmed a way to report multiple ordering professionals on all relevant claim types.

CMS also indicated that they will be releasing additional claims processing instructions that allow more than one ordering provider to be reported on the professional component/global claim, one of the major barriers to implementation in years past.

Reference: https://www.federalregister.gov/d/2021-23972/p-2211

Will Medicare still pay if the ordering professional orders an image that does not adhere to the AUC?

Yes, if medical necessity criteria is met. Medicare will not solely deny the claim based on the results of the AUC consultation. Eventually, ordering professionals who have the highest rates of non-adherence will be subject to a form of pre-authorization. Ordering professionals will be evaluated based on the “priority clinical areas” and the exact details of which ordering professionals and the timing for this component of the program are still to be determined by CMS. 

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

Can imaging center, radiology department staff, or radiologists themselves consult the qCDSM on behalf of the ordering professional?

No. In the 2022 MPFS Final Rule, CMS very explicitly confirmed that “Unless they are also serving as the ordering professional, furnishing professionals may not consult AUC on behalf of or in place of the ordering professional.”

Reference:  https://www.federalregister.gov/d/2021-23972/p-2174  

Does the furnishing professional need to consult AUC if they determine that the advanced image ordered needs to be modified?

No. However, furnishing professionals in both hospital and non-hospital settings need to append the AUC consultation information provided by the ordering professional specific to the original order.

In non-hospital settings, the Medicare Benefit Policy Manual Chapter 15, section 80.6.1-4 describes the situations in which the furnishing professionals may modify orders.

In hospital settings, furnishing professionals may modify orders according to their hospital’s policies and procedures.

Reference: https://www.federalregister.gov/d/2021-23972/p-2188

If the furnishing professional requests a modified order and is able to contact the ordering professional, does the ordering professional have to re-consult AUC a second time?

Yes. The ordering professional would be required to consult AUC through a qCDSM for the modified order.

The AUC information from the second consultation should go on the claim.

What happens to claims that fail AUC Claims Processing Edits?

CMS solicited comments on whether they should return or deny claims that fail AUC claims processing edits. AHRA commented, and CMS agreed that claims that fail these edits should be returned for resubmission instead of denied. However, there may be scenarios where the furnishing professionals would prefer a denial. Therefore, AHRA will be requesting that CMS create or identify a modifier that allows the advanced imaging claim to be denied.

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

• Clarifying how claims with more than 4 modifiers per line may be reported on the UB-04 claim form.
• Publication of a modifier to allow radiologists to report that the technical component of an image was performed in a non-applicable setting.

Resources

Where can I get more information?

CMS link

Link to the relevant section of the 2022 Medicare Physician Fee Schedule (MPFS) Final 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

MLN Matters – Appropriate Use Criteria for Advanced Diagnostic Imaging – Approval of Using the K3 Segment for Institutional Claims: https://www.cms.gov/files/document/se20002.pdf

MLN Matters - Appropriate Use Criteria for Advanced Diagnostic Imaging - Voluntary Participation and Reporting Period - Claims Processing Requirements ? HCPCS Modifier QQ: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10481.pdf

MLN Matters – Appropriate Use Criteria for Advanced Imaging ? Analysis and Design: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2016-Transmittals-Items/R1699OTN: