Appropriate Use Criteria Testing Period Extended
The Appropriate Use Criteria (AUC) program, slated to begin Jan. 1, 2021, has been postponed. A notice on the Centers for Medicare & Medicaid Services (CMS) website states that the educational and operations testing period will now continue through 2021.
“We encourage stakeholders to use this period to learn, test and prepare for the AUC program,” CMS states in the notice.
What is AUC?
The AUC program is a provision of the Protecting Access to Medicare Act of 2014 (PAMA), which requires CMS to establish a system for ensuring advanced diagnostic imaging services provided to Medicare patients are warranted.
Advanced imaging services include:
- Computed tomography (CT)
- Magnetic resonance imaging (MRI)
- Nuclear medicine
- Positron emission tomography (PET)
In the future, CMS will use data they collect from the program to identify outliers. CMS intends to require these outliers to receive prior authorization for their services, but it will have to get this component of the AUC program through rulemaking first.
Who Must Comply to the AUC?
Physicians and other qualified healthcare practitioners who order advanced diagnostic imaging in a physician’s office, hospital outpatient department or emergency department, an ambulatory surgical center, or an independent diagnostic testing facility (IDTF) will be subject to AUC for claims paid under one of the following payment systems:
- Medicare Physician Fee Schedule (MPFS)
- Outpatient Prospective Payment System (OPPS)
- Ambulatory Surgical Center Payment System (ASC PS)
After the program is implemented, such claims without AUC consultation information will be denied.
AUC Program History
There are four components to the AUC program, thus far, each implemented in separate rulemaking:
- Provider-led entities (PLEs) – In the 2016 MPFS final rule, CMS addressed the initial component of the new Medicare AUC program: defining provider-led entities (PLEs) and establishing the process by which PLEs may become qualified to develop, modify, or endorse AUC. CMS defined the term PLE to include national professional medical societies, health systems, hospitals, clinical practices, and collaborations of entities such as the High Value Healthcare Collaborative or the National Comprehensive Cancer Network.
- Clinical Decision Support Mechanisms (CDSMs) – In the 2017 MPFS final rule, CMS finalized the definition of a CDSM as “an interactive, electronic tool for use by clinicians that communicates AUC information to the user and assists them in making the most appropriate treatment decision for a patient’s specific clinical condition.” CMS also identified the requirements CDSMs must meet for qualification and established a process by which CDSMs may become qualified. The AUC program requires ordering professionals to consult a qualified CDSM prior to ordering advanced diagnostic imaging services for patients with Medicare Part B.
Also, in the CY 2017 MPFS final rule, CMS established a list of priority clinical areas:
- Coronary artery disease (suspected or diagnosed)
- Suspected pulmonary embolism
- Headache (traumatic and nontraumatic)
- Hip pain
- Low back pain
- Shoulder pain (to include suspected rotator cuff injury)
- Cancer of the lung (primary or metastatic, suspected or diagnosed)
- Cervical or neck pain
Each individual criterion is an evidence-based guideline for a particular clinical scenario, and each scenario starts with a patient’s presenting symptoms or condition.
- In the 2018 MPFS final rule, CMS delayed the consultation and reporting requirements for the AUC program from Jan. 1, 2019, to Jan. 1, 2020. As a compromise, they established a voluntary period during which early adopters could begin reporting limited consultation information on Medicare claims from July 2018 through Dec. 2019. During the voluntary participation period, providers were instructed to append modifier QQ to claims for applicable advanced diagnostic imaging services.
- As finalized in the 2019 MPFS final rule, on Jan. 1, 2020, CMS began an educational and operations testing period, at which time physicians and other qualified healthcare professionals could begin reporting AUC-related modifiers and CDSM codes on claims.
Coding Compliance for AUC Program
The following HCPCS Level II modifiers were established for this program for placement on the same line as the CPT® code for the advanced diagnostic imaging service:
- MA – Ordering professional is not required to consult a clinical decision support mechanism due to service being rendered to a patient with a suspected or confirmed emergency medical condition.
- MB – Ordering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of insufficient internet access.
- MC – Ordering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of electronic health record or clinical decision support mechanism vendor issues.
- MD – Ordering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of extreme and uncontrollable circumstances.
- ME – The order for this service adheres to the appropriate use criteria in the clinical decision support mechanism consulted by the ordering professional.
- MF – The order for this service does not adhere to the appropriate use criteria in the qualified clinical decision support mechanism consulted by the ordering professional.
- MG – The order for this service does not have appropriate use criteria in the clinical decision support mechanism consulted by the ordering professional.
- MH – Unknown if ordering professional consulted a clinical decision support mechanism for this service, related information was not provided to the furnishing professional or provider.
- QQ – Ordering professional consulted a qualified clinical decision support mechanism for this service and the related data was provided to the furnishing professional (effective date: 7/1/18).
See MLN Matters article MM11268 for a code list of applicable advanced diagnostic imaging services.
Claims that report modifier ME, MF, or MG on the claim line for an advanced diagnostic imaging service should additionally contain a G code (G1000-G1023) on a separate claim line to report which qualified CDSM was consulted (multiple G codes on a single claim is acceptable). These G codes do not have associated payment rates and are for reporting purposes only.
Note: Voluntary participation in this program is a quality measure in the Merit-Based Incentive Program (MIPS) for which providers can receive credit toward their final MIPS score.
As soon as the program is implemented, “Claims that fail to append this information will not be paid,” CMS states on its website. With an implementation date of Jan. 1, 2022, now is a good time to establish a policy for this reporting requirement. You’ve got nothing to lose this year, but next year will be a different story.