CMS to Implement Advanced Diagnostic Imaging Monitoring Program
The Centers for Medicare & Medicaid Services (CMS) has a date in mind for implementing the Appropriate Use Criteria (AUC) program for advanced diagnostic imaging services.
In the 2018 Medicare Physician Fee Schedule (MPFS) proposed rule, CMS proposes Jan. 1, 2019, as the date when ordering professionals would need to consult specified applicable AUC using a qualified clinician decision support mechanism (CDSM) when ordering applicable imaging services; and, furnishing professionals would need to report consultation information on the Medicare claim (for services paid under the MPFS, as well as the Outpatient Prospective Payment System and the Ambulatory Surgery Center Payment System).
CMS has been establishing the AUC program in components:
- In the 2016 MPFS final rule, CMS established an evidence-based process and transparency requirements for the development of AUC; defined provider-led entities (PLE); and established the process for PLEs to become qualified to develop, modify, or endorse AUC. The first list of qualified PLEs was posted on the CMS website in June 2016.
- In the 2017 MPFS final rule, CMS defined CDSMs; identified the requirements CDSMs must meet for qualification; established a process for CDSMs to become qualified; defined applicable payment systems; specified the first list of priority clinical areas; and identified exceptions. The first list of qualified CDSMs was posted on the CMS website in conjunction with the 2018 MPFS proposed rule.
- In the 2018 MPFS proposed rule, CMS is proposing the start date of the AUC program, as well as modifications to the policy related to significant hardship exceptions. CMS is also soliciting feedback on details regarding how to include AUC consultation information on Medicare Part B claims.
If finalized, CMS will require the following information on the Medicare claim:
- Which qualified CDSM was consulted;
- Whether the service ordered adheres to specified applicable AUC; and
- The National Provider Identifier (NPI) of the ordering professional (if different than the furnishing professional).
To that end, CMS is proposing to implement a series of HCPCS Level III G codes and associated HCPCS Level II modifiers. Until these G codes can be implemented, however, CMS is proposing to establish a temporary, generic G code to report that a qualified CDSM was consulted and another temporary, generic G code to report a CDSM was not consulted.
The final modifiers would attest:
- The imaging service adheres to applicable AUC;
- The imaging service does not adhere to AUC; or
- AUC is not applicable.
Other modifiers CMS is proposing would attest:
- The imaging service was ordered for a patent with an emergency medical condition; or
- The ordering professional has a significant hardship exception.
According to CMS, clinicians should anticipate a voluntary reporting period to be available beginning sometime in 2018.
CMS says, “The goal of evidence-based AUC is to assist clinicians in ordering the most appropriate imaging service for their patients’ specific clinical scenarios.” However, because some stakeholders have expressed a concern that the program may inadvertently encourage physicians to order imaging services that they do not believe are right for their patients, CMS is asking for public comment on such potential unintended consequences.
Read Section III.E of the proposed rule for more information about the AUC program. Commenting instructions appear at the beginning of the document.
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