Appropriate Use Criteria | RadNet
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Congress has mandated that ordering providers show that they consulted appropriate use criteria (AUC) when ordering advanced imaging for their Medicare patients. In other words, they must show that they sought support for that clinical decision.

RadNet is ready with an operational strategy for this new requirement. We’ve leveraged our regulatory expertise across all operations to help our providers comply with the mandate—and understand AUC.

What’s required?

Starting January 1, 2020, ordering providers must consult AUC via a qualified Clinical Decision Support Mechanism (qCDSM) when ordering advanced imaging (MR, CT, PET, NM) for Medicare* patients. To ensure reimbursement by the Centers for Medicare and Medicaid Services for those studies, ordering providers must document and submit three points of compliance:

1. G-Code

Indicates the qCDSM, such as NDSC’s CareSelect†, that was consulted prior to placing the order.

2. Modifier
Indicates whether the order:
a) adhered to AUC
b) did not adhere to AUC, or
c) was not applicable to AUC.

3. NPI
The national provider identifier of the ordering professional (the referrer).

*Special programs, such as Medicare Advantage, are excluded. The mandate applies to traditional Medicare patients only.

†National Decision Support Company’s CareSelect is used here only as an example; CMS qualifies all Clinical Decision Support Mechanisms.

Any exceptions?

Ordering professionals are exempt from consulting and reporting AUC only under these circumstances:

  • Emergency services in life-threatening situations

  • Services for an inpatient for whom payment is made under Medicare Part A, or for Medicare Advantage payments

  • A hardship exception, such as natural disasters, no broadband internet, or EHR system failures.

GOOD TO KNOW

For the ordering provider’s edification, the qCDSM returns a score to indicate how closely the ordered exam corresponds to AUC. Depending on the qCDSM, that score is shown as a color (red, yellow, green), a number (1-9), or letter.

What’s our role?

As a leader in radiology, RadNet is very involved in advocacy and regulatory activities in the industry. Our entire enterprise—from I.T. to clinical operations—has implemented changes to respond to and accommodate CDS. Referrers and patients will experience no disruption in services, with the ability to connect via phone, fax, portal, or EHR. We offer outreach and education to assist RadNet’s referring physicians as they make adjustments to meet these new consultation requirements.

Frequently Asked Questions

What happens if I don’t provide AUC consultation information?

Without a documented consult, rendering providers will not receive Medicare payment for the procedure. Ordering providers are not mandated to adhere strictly to the AUC, just to consult AUC. There is no “hard stop” to the ordering process. 

Providers that do comply can receive Merit-based Incentive Payment System (MIPS) Improvement Activity Points and the Promoting Interoperability Bonus from CMS.

What about non-advanced diagnostic exams? Do I need to consult AUC?

Ordering professionals are not required to consult AUC for non-advanced diagnostic exams. The PAMA legislation mandates that AUC be consulted for all advanced diagnostic imaging services.

When does all this start?

The Medicare AUC program is scheduled to begin on  January 1, 2020, with an educational and operations testing period. During that testing period, advanced imaging claims will be paid whether or not they correctly include AUC consultation information. CMS will probably issue additional guidance on the AUC program roll-out in the coming weeks.)

My EMR doesn’t have an interface to a qCDSM. What are my options?

RadNet offers a free portal that integrates a qCDSM that providers can use to consult AUC. Also, CMS has identified 22 qualified and preliminarily-qualified Clinical Decision Support Mechanisms. Click here for the current list of qCDSMs. Three of those qCDSMs offer a free online AUC tool.

What exactly has to be on a claim to Medicare?

Medicare claims must include the National Provider Identifier of the ordering provider, the qualified Clinical Decision Support Mechanism used by the ordering provider, and whether the ordered procedure adhered to the AUC.

Will reports be different as a result of AUC?

No. Radiology reports are unaffected by AUC, with no change in lexicon or approach.

Who is allowed to perform the qCDSM consultation?

The consultation can be performed by the ordering clinician or a delegate, under the clinician's direction, who has sufficient clinical knowledge, qCDSM expertise, and the means to communicate the AUC results to the ordering clinician. The AUC information (G-code and modifier) must accompany the order for the advanced diagnostic imaging study.

I don’t understand all the requirements. What should I do?

RadNet has all the resources you need. We are ready with education and outreach to help you gain the knowledge you need to comply with the mandate and feel comfortable with the changes. To read about AUC, you can also click here (detail) or here (infographic).