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AUC Pivot – Take 5


By Melody Mulaik

The implementation of Appropriate Use Criteria (AUC) consultation has been delayed many times since its original implementation date of January 1, 2017 set forth in the Protecting Access to Medicare Act of 2014 (PAMA). Everyone in the radiology industry is aware of the high-level requirements of the legislation. The devil is in the details at this point.

In the 2018 Medicare Physician Fee Schedule (MPFS) Final Rule, CMS announced the consultation requirement would go into effect January 1, 2020. In January 2020 a one year “educational and operations testing period” began which CMS extended to two years by posting an update on its AUC webpage in August, 2020. In the 2022 MPFS Proposed Rule, CMS expressed concerns around the complexities, scope and application of AUC program claims processing edits and is requesting stakeholder feedback regarding the implementation and claims processing issues and the start date of the payment penalty phase. Additionally, CMS acknowledges that due to the challenges and practice disruptions experienced during the Public Health Emergency (PHE) for COVID-19, additional time may be needed to prepare for the payment penalty phase.

CMS believes that the earliest that its claims processing system can begin screening claims using the AUC program claims processing edits for the payment penalty phase is October 2022. Since this timing does not align with the typical CMS annual update cycle, CMS believes that the earliest practicable effective date for the AUC program claims processing edits and payment penalty phase would be January 1, 2023. Therefore, CMS’s proposal is a flexible effective date for AUC program claims processing edits and payment penalty phase to begin the later of January 1, 2023, or the January 1 that follows the declared end of the PHE for COVID-19.

While the proposed delay is certainly the most noteworthy item associated with AUC in the proposed rule, there are also some other proposed clarifications and/or charges that are noteworthy. CMS proposes that when the furnishing professional for a study that required AUC consultation needs to modify an order and/or perform additional studies (in compliance with CMS guidelines) then neither the ordering provider nor the furnishing professional are required to perform an additional AUC consultation. This is technically not new information, but it is good to have this clarification should it be set forth in the MPFS Final Rule.

The exemption of Critical Access Hospitals (CAHs) has been stated by CMS in the past but there remained the lingering question for some as to whether this exemption would also apply to the interpreting radiologist. To address this, CMS proposes to clearly define an exception that claims submitted by providers for the professional component of an advanced diagnostic study in a CAH would not be subject to the AUC program.

There are two important scenarios that CMS is seeking feedback on that have a very substantial impact on all stakeholders responsible for submitting claims with AUC information. The first is inpatients who are converted to outpatient status and the second is patients who have Medicare as their secondary payer. Both scenarios can create operational challenges for both the technical and professional sides to ensure correct billing. CMS’s proposal to exclude these claims would be welcomed by everyone in the industry.

There are also proposed changes to the existing modifiers utilized to report adherence to the AUC consultation requirements. CMS proposes to keep the MH modifier and expand its definition from communicating only that it is unknown whether or not an ordering provider performed the AUC consultation to also include situations where the ordering providers is not required to consult AUC (CAH, etc.).

There are other elements that CMS includes in the proposed rule language regarding AUC so all of the information should be reviewed in its entirety. With all of the delays, CMS’s admitted challenges with processing claims and, most importantly, greater priorities for health care providers during this Public Health Emergency (PHE) perhaps it is time for bigger discussion as to whether or not the current program structure really addresses the originally defined goals.

Melody W. Mulaik, MSHS, CRA, RCC, RCC-IR, CPC, COC, FAHRA, is the president of Revenue Cycle and Coding Strategies Inc.



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