After multiple years of delays the wait is finally over – well almost. January 1, 2020 ushered in the testing period of a program that been the topic of discussion for many years. During 2020, the Centers for Medicare and Medicaid Services (CMS) will not deny any claims solely based on the submission (or lack thereof) of Appropriate Use Criteria (AUC) reporting criteria. Beginning January 1, 2021, this will change as CMS will deny payment to both the facility that provided the imaging and the interpreting provider if the required AUC elements such as the newly established G-codes and modifiers are not reported.
Ordering physicians and practitioners (“ordering professionals”) will be required to consult AUC for all advanced imaging studies billed under the Medicare Physician Fee Schedule (MPFS), the Outpatient Prospective Payment System (OPPS) and the Ambulatory Surgical Center (ASC) Payment System, including those performed in a physician office, hospital outpatient department (including emergency department), IDTF or ambulatory surgery center.
There are few exceptions to note. The AUC consultation requirement does not apply to imaging exams performed on inpatients and paid under Medicare Part A. It also does not apply to patients with emergency medical conditions as defined by the Emergency Medical Treatment & Labor Act (EMTALA), whether confirmed or suspected, or when the ordering physician or practitioner has received a hardship exception. Any ordering professional experiencing insufficient Internet access, EHR or CDSM vendor issues, or extreme uncontrollable circumstances (including natural or manmade disasters) will not be required to consult the AUC using a qualified CDSM. These circumstances will be self-attested at the time of placing the order.
On July 26, 2019 Centers for Medicare and Medicaid Services (CMS) finally released the reporting requirements for Appropriate Use Criteria (AUC) consultation for Advanced Diagnostic Imaging exams. Beginning January 1, 2020 CMS has indicated claims processing systems will be prepared to accept claims with Current Procedural Terminology (CPT®) or HCPCS C code, for advanced diagnostic imaging along with a line item HCPCS modifier. The modifier will identify what level of the AUC was followed or to identify an exception to the program. Table 1 includes the modifiers for reporting under the AUC.
If a claim includes modifier ME, MF or MG with the advanced diagnostic imaging service, a separate G-code is required to report which qualified CDSM consulting the ordering provider consulted when ordering the exam. CMS has indicated that multiple G-codes can be reported on a single claim.
Each CDSM consulted by the ordering professional has a unique G-code for reporting on the claim form. The listing of the specific G-codes and the CDSMs they represent can be found in Table 2 in the MLN Matters MM11268: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11268.pdf. This same transmittal also includes the full list of HCPCS advanced imaging procedure codes which are included in the AUC program. This list has not been updated for the new 2020 nuclear medicine and PET codes so watch for an updated list.
As you work with your ordering providers for a successful implementation keep in mind that for them taking the time to perform the AUC consultation is defined by CMS as a High-Weight Improvement Activity for the Medicare Access and CHIP Reauthorization Act (MACRA) quality program. Additionally, this activity is eligible for 10% bonus points in the Promoting Interoperability (PI) performance category. Also, the Cost Display for Laboratory and Radiologic Orders is defined as a Medium-Weight Improvement Activity, which is also eligible for a 10% bonus points award in the PI performance category. So, in addition to being compliant with a regulatory mandate, your ordering providers are getting some “credit” for the extra work involved in participating in AUC.
Even though 2020 is a testing year, and there will be no financial impact to the claims submitted to CMS for advanced diagnostic imaging service, it is vital that you ensure that all the required system changes are in place and working correctly. In the absence of new guidance from CMS lack of compliance with these new guidelines will result in payment denials beginning on January 1, 2021.
Melody W. Mulaik, MSHS, CRA, RCC, RCC-IR, CPC, COC, FAHRA, is the president of Revenue Cycle and Coding Strategies Inc.