Add Advance Use Criteria to the Mix
The recipe for AUC yields improved quality, reduces unnecessary imaging, and lowers costs.
The Protecting Access to Medicare Act of 2014 (Public Law 113-93) directed the Centers for Medicare & Medicaid Services (CMS) to establish a program to promote the use of appropriate use criteria (AUC) for advanced diagnostic imaging services. As a result, Medicare will require ordering professionals to consult specified AUC prior to ordering advanced diagnostic imaging services for certain medical conditions. This mandate is not just a “radiologist issue;” the requirements could significantly affect ordering and performing professionals of all specialties.
The goal of evidence-based AUC is to assist clinicians in ordering the most appropriate imaging service for their patients’ specific clinical scenarios. Appropriateness criteria has been used for years, and has shown to improve quality, reduce unnecessary imaging, and lower costs.
Ordering Professionals’ Responsibilities
Beginning Jan. 1, 2020, ordering professionals will be responsible for checking (i.e., consulting) AUC through a qualified Clinical Decision Support Mechanism (CDSM), and must communicate information on that consultation to the furnishing professional. Information related to the AUC consultation is communicated as part of the order sent to the furnishing professional. CMS is still working on a unique consultation identifier system. Until CMS develops the taxonomy for the identifier, the ordering professional must send the furnishing professional the following information:
- Which qualified CDSM was consulted for the service;
- Whether the service ordered would adhere to the applicable AUC;
- Whether the service ordered would not adhere to the applicable AUC;
- Whether such AUC was not applicable to the service ordered; and
- The ordering professional’s national provider identifier (NPI).
Ordering professionals are only required to consult AUC if the technical component of the study is performed in an applicable setting, under an applicable payment system, and for an applicable clinical priority area.
One of the questions posed to CMS during the rulemaking process was whether a designee in an ordering professional’s practice could consult on behalf of the ordering professional. CMS specified that they require the ordering professional consult the AUC. CMS may develop specific policy to ensure circumvention of this requirement does not occur.
Outlier ordering professionals will be subject to prior authorization for these services beginning Jan. 1, 2020. CMS will discuss details around outlier calculations and prior authorization in the 2019 Medicare Physician Fee Schedule Proposed Rule.
Note: Medicare Part B professional claims do not require AUC consultation when the technical component is performed on a hospital inpatient or billed under Medicare Part A.
Furnishing Professionals’ Claim Reporting Requirements
Furnishing professionals must report the AUC consultation information on the Medicare claim for applicable services ordered on or after Jan. 1, 2020. CMS will continue to pay claims through Dec. 31, 2020, regardless of whether this information is submitted.
Effective July 1, 2018, report HCPCS Level II modifier QQ Ordering professional consulted a qualified clinical decision support mechanism for this service and the related data was provided to the furnishing professional when the furnishing professional is aware of the result of the ordering professional’s consultation with a CDSM for the ordered service. Report modifier QQ on the same claim line as the CPT® code for an applicable advanced diagnostic imaging service on both the facility and professional claims. Prior to Jan. 1, 2020, it’s voluntary for the furnishing professional to submit modifier QQ.
Beginning Jan. 1, 2021, payment may be made to the furnishing professional only if the claim for the advanced diagnostic imaging services includes the AUC consultation indicator. You will need to include the required information on the practitioner claim containing the professional component of the imaging service or on the hospital outpatient claim for the technical component of the imaging study.
When the furnishing professional must update or modify the order for an advanced diagnostic imaging service (as detailed in the Medicare Benefit Policy Manual, Pub. # 100–02, Chapter 15, sections 80.6.2–4), the Medicare claim should reflect the AUC consultation information (provided by the ordering professional with the original order) to show the requisite AUC consultation occurred. In future rulemaking, CMS intends to establish a means to account for instances when the order must be updated or modified.
This flowchart illustrates how a typical workflow may occur:
AUC and MIPS
The 2018 Quality Payment Program Final Rule gave Merit-based Incentive Payment System (MIPS) credit to ordering professionals for consulting AUC using a qualified CDSM as a high-weight improvement activity for the performance period beginning Jan. 1, 2018. This was done to incentivize early use of qualified CDSMs to consult AUC by MIPS eligible clinicians who want to improve patient care and better prepare themselves for the AUC program.
A Recipe for AUC Success
Let’s compare the consulting AUC process with how to bake a cake:
- The chef (the ordering professional) mixes together water and a cake mix (the patient’s clinical presentation and ordered tests) and pours the mix into a baking pan.
- The chef then pushes the baking pan into the oven and turns on the timer in accordance with the instructions on the mix (the ordering professional enters the patient details into the CDSM).
- The oven cooks the mix according to the recipe and the time selected according to the cookbook (CDSM searches through the AUC database provided by the provider-led entity to determine whether the ordered test is appropriate based on the patient’s clinical presentation.
- When the mix is done cooking, the cake is extracted from the oven and it is either just right, overdone, or underdone (the CDSM provides a response to the ordering professional on whether the ordered test is appropriate, may be appropriate, or rarely appropriate, or similar wording).
- The chef serves the cake to the customer (the ordering professional sends the CDSM response to the furnishing professional via the order).
- The customer eats the cake (the furnishing professional submits the claim to Medicare with the information sent by the ordering professional).
Key Terms, Applicable Settings and Services, and More
Below are some key terms you’ll need to know to meet your responsibilities Protecting Access to Medicare Act of 2014, relative to appropriate use criteria (AUC).
Appropriate Use Criteria (AUC)
AUC is a set of standards developed by a medical specialty society which indicate whether a particular considered service is appropriate based on the patient’s presenting symptoms and clinical condition. For example, will the considered test yield helpful results based on the patient’s presenting symptoms and clinical condition or would another test or service yield better results?
Provider-led Entity (PLE)
A PLE is a national professional medical specialty society or other organization comprised primarily of providers or practitioners who, either within the organization or outside of the organization, predominantly provide direct patient care.
To be qualified by the Centers for Medicare & Medicaid Services (CMS), a PLE must adhere to evidence-based processes when developing or modifying AUC. PLEs must apply to CMS to become qualified and once approved, must re-apply every five years.
Clinical Decision Support Mechanism (CDSM)
CDSMs are the electronic portals through which practitioners access AUC during the patient workup. A CDSM may be a module within a certified electronic health record (EHR) or it may be a private sector tool independent from certified EHR technology.
Practitioners who do not have access to a qualified CDSM within their EHR may experience greater interruptions to their clinical workflows due to issues of interoperability or availability than practitioners who do not have to leave their EHR environment to consult a qualified CDSM.
Priority Clinical Areas
The following clinical areas are where the ordering professional is required to consult AUC prior to ordering an advanced diagnostic imaging study. The current list of priority clinical areas represents about 40 percent of advanced diagnostic imaging services paid for by Medicare in 2014.
- Coronary artery disease (suspected or diagnosed)
- Suspected pulmonary embolism
- Headache (traumatic or nontraumatic)
- Hip pain
- Low back pain
- Shoulder pain (including suspected rotator cuff injury)
- Cancer of the lung (primary or metastatic, suspected, or diagnosed)
- Cervical or neck pain
- Physician’s office
- Hospital outpatient department (including an emergency department)
- Ambulatory surgical center (ASC)
- Any other provider-led outpatient setting
Note: The applicable setting is where the imaging service is furnished, not the setting where the imaging service is ordered.
Applicable Diagnostic Imaging Services
- Diagnostic magnetic resonance imaging
- Computed tomography
- Nuclear medicine (including positron emission tomography)
- Ultrasound and fluoroscopy services are excluded.
Note: CMS published a list of applicable CPT® codes via Transmittal # 2040 (Change Request 10481), dated March 2, 2018.
Applicable Payment Systems
- Medicare Part B physician fee schedule
- Prospective payment system for hospital outpatient department services
- ASC payment system
Claims for services for which payment is not made under these three payment systems are not required to include consultation-related information.
Exceptions to Consulting
and Ordering Requirements
- Inpatients and services for which payment is made under Medicare Part A
- Emergency services when provided to individuals with “emergency conditions”
- Ordering professionals who obtain an exception due to a significant hardship
18-month Voluntary Reporting Period: July 1, 2018, through Dec. 31, 2019:
- During the voluntary period, there is no requirement for ordering professionals to consult AUC or furnishing professionals to report consultation information.
- Early adopters can begin reporting limited consultation information on Medicare claims.
- HCPCS Level II modifier QQ Ordering professional consulted a qualified clinical decision support mechanism for this service and the related data was provided to the furnishing professional is available to furnishing professionals and facilities reporting AUC consultation information. This modifier only identifies that AUC was consulted and not the result of the consultation, and it will be temporary as CMS implements reporting with the unique consultation identifier. Report the modifier on the same claim line as the CPT® code for the advanced diagnostic imaging service for both the facility and professional claims.
One-year Educational and Operations Testing Period: Jan. 1, 2020, through Dec. 31, 2020:
- Ordering professionals must consult specified applicable AUC through qualified CDSMs for applicable imaging services furnished in an applicable setting, paid for under an applicable payment system and ordered on or after Jan. 1, 2020.
- Furnishing professionals must report the AUC consultation information on the Medicare claim for these services ordered on or after Jan. 1, 2020.
- CMS will continue to pay claims whether they correctly include such information.
Requirements in Full Effect: Jan. 1, 2021, and Forward:
- The only change from the educational and operations testing period is that CMS will deny the furnishing professional’s claim if the AUC consultation information is not reported on the Medicare claim.
Because payment for the furnishing professional’s service will ultimately be tied to claim reporting requirements beginning Jan. 1, 2021, a furnishing professional may choose not to perform a study if the ordering professional does not provide the required AUC consultation information.
Resource: Medicare Benefit Policy Manual, Pub. # 100–02, Chapter 15, sections 80.6.2–4