AUC - Frequently Asked Questions
AUC - Frequently Asked Questions
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?
Full implementation begins on January 1, 2021.
We are currently in the “educational and operational testing period” which began on January 1, 2020.
What does the educational and operational testing period entail?
The educational and operational testing period begins January 1, 2020 and will last two years. 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.
UPDATE: CMS has clarified that for CY 2020, applicable imaging claims with no AUC-related information will not be denied.
"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."
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
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).
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.
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.
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.
Does AUC apply to Rural Health Clinics (RHC)?
Clinicians including Physicians, Nurse Practitioners, Physician Assistants who work in Rural Health Clinics 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 a 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.
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.
What G-codes can be used to report qCDSMs?
The following G-codes are used to report the qCDSM used by the ordering professional:
Appropriate Use Criteria G-Codes
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
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
Ordering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of insufficient internet access
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
Ordering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of extreme and uncontrollable circumstances
The order for this service adheres to the appropriate use criteria in the clinical decision support mechanism consulted by the ordering professional
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
The order for this service does not have appropriate use criteria in the clinical decision support mechanism consulted by the ordering professional
Unknown if ordering professional consulted a clinical decision support mechanism for this service, related information was not provided to the furnishing professional or provider
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)
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.
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.”
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?
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
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