Appropriate Use Criteria (AUC) in Coding, Reimbursement, and Clinical Practice

Appropriate Use Criteria (AUC) in Coding, Reimbursement, and Clinical Practice

Within the next several years, providers will be required to observe appropriate use criteria (AUC) as a condition of payment when reporting certain services for Medicare beneficiaries. Coders will need to be aware of this development, as it will begin to affect claims coding as early as July 2018.

As described by AAOS:

Appropriate Use Criteria (AUC) specify when it is appropriate to use a procedure. An “appropriate” procedure is one for which the expected health benefits exceed the expected health risks by a wide margin. Often, sound data is not available or does not provide evidence that is detailed enough to apply to the full range of patients seen in everyday clinical practice. Nevertheless, physicians must make daily decisions about when to use or not use a particular procedure. AUCs facilitate these decisions by combining the best available scientific evidence with the collective judgment of physicians in order to determine the appropriateness of performing a procedure.

For its purposes, the Centers for Medicare & Medicaid Services (CMS) defined appropriate use criteria in the 2016 Physician Fee Schedule final rule:

Appropriate use criteria (AUC) means criteria only developed or endorsed by national professional medical specialty societies or other provider-led entities, to assist ordering professionals and furnishing professionals in making the most appropriate treatment decision for a specific clinical condition for an individual. To the extent feasible, such criteria must be evidence-based. An AUC set is a collection of individual appropriate use criteria. An individual criterion is information presented in a manner that links: a specific clinical condition or presentation; one or more services; and, an assessment of the appropriateness of the service(s).

However they are defined, AUC are meant to guide healthcare providers’ treatment decisions to maximize patient outcomes, while minimizing inappropriate or ineffective utilization of services.

How AUC Are Linked to Reimbursement

The Protecting Access to Medicare Act of 2014 (PAMA) established a program that requires healthcare providers to adhere to AUC when ordering “advanced diagnostic imaging services” for Medicare beneficiaries. A clinical decision support mechanism (CDSM) is the electronic portal through which practitioners access AUC. CMS requires that a CDSM be “qualified” for compliance under PAMA. You can find a list of qualified CDSMs on the CMS website.

Voluntary Reporting of AUC Consults Is About to Begin

Full implementation of PAMA is expected in early 2020; however, beginning July 1, 2018, ordering professionals may voluntarily report their consultation of AUC through a qualified CDSMs by appending modifier QQ Ordering professional consulted a qualified clinical decision support mechanism for this service and the related data was provided to the furnishing professional to their claims. As detailed in MLN Matters Number: MM10481, modifier QQ is:

  • Used when the furnishing professional is aware of the result of the ordering professional’s consultation with a CDSM for that patient;
  • Reported on both the facility and professional claim; and,
  • Reported on the same claim line as the CPT code for an advanced diagnostic imaging service furnished in an applicable setting and paid for under an applicable payment system.

A list of affected applicable CPT® codes, to which modifier QQ may be appended, is found in CMS Transmittal 2040:

Magnetic Resonance Imaging

70336, 70540, 70542, 70543, 70544, 70545, 70546, 70547, 70548, 70549, 70551, 70552, 70553, 70554, 70555, 71550, 71551, 71552, 71555, 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72159, 72195, 72196, 72197, 72198, 73218, 73219, 73220, 73221, 73222, 73223, 73225, 73718, 73719, 73720, 73721, 73722, 73723, 73725, 74181, 74182, 74183, 74185, 75557, 75559, 75561, 75563, 75565, 76498

Computerized Tomography

70450, 70460, 70470, 70480, 70481, 70482, 70486, 70487, 70488, 70490, 70491, 70492, 70496, 70498, 71250, 71260, 71270, 71275, 72125, 72126, 72127, 72128, 72129, 72130, 72131, 72132, 72133, 72191, 72192, 72193, 72194, 73200, 73201, 73202, 73206, 73700, 73701, 73702, 73706, 74150, 74160, 74170, 74174, 74175, 74176, 74177, 74178, 74261, 74262, 74712, 74713, 75571, 75572, 75573, 75574, 75635, 76380, 76497

Single-Photon Emission Computed Tomography

76390

Nuclear Medicine

78012, 78013, 78014, 78015, 78016, 78018, 78020, 78070, 78071, 78072, 78075, 78099, 78102, 78103, 78104, 78110, 78111, 78120, 78121, 78122, 78130, 78135, 78140, 78185, 78191, 78195, 78199, 78201, 78202, 78205, 78206, 78215, 78216, 78226, 78227, 78230, 78231, 78232, 78258, 78261, 78262, 78264, 78265, 78266, 78267, 78268, 78270, 78271, 78272, 78278, 78282, 78290, 78291, 78299, 78300, 78305, 78306, 78315, 78320, 78350, 78351, 78399, 78414, 78428, 78445, 78451, 78452, 78453, 78454, 78456, 78457, 78458, 78459, 78466, 78468, 78469, 78472, 78473, 78481, 78483, 78491, 78492, 78494, 78496, 78499, 78579, 78580, 78582, 78597, 78598, 78599, 78600, 78601, 78605, 78606, 78607, 78608, 78609, 78610, 78630, 78635, 78645, 78647, 78650, 78660, 78699, 78700, 78701, 78707, 78708, 78709, 78710, 78725, 78730, 78740, 78761, 78799, 78800, 78801, 78802, 78803, 78804, 78805, 78806, 78807, 78811, 78812, 78813, 78814, 78816, 78999

Applicable settings for the use of modifier QQ currently include physician offices, hospital outpatient departments, and ambulatory surgical centers.

For now, Medicare Area Contractors (MACs) will continue to pay claims for services listed above, regardless of whether the ordering provider followed AUC as accessed via a qualified CDSM, and regardless of whether modifier QQ is appended. When PAMA is fully implemented, however, providers who order advanced imaging services in the absence of, or contrary to, appropriate use criteria, may be subject to non-payment of claims and prepayment review.

John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

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About Has 556 Posts

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.

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