Radiology Appropriate Use Criteria (AUC)
Congress has mandated that ordering providers show that they consulted appropriate use criteria (AUC) when ordering advanced imaging (MR, CT, PET, NM) for their Medicare patients. The Centers for Medicare & Medicaid Services (CMS) finalized an extension of the educational and testing period for the Medicare AUC program until at least the end of 2022.
RadNet will be ready to accept AUC information during the educational and testing period.
What’s the latest?
The educational and operations testing period for the AUC program is extended through CY 2022. There are no payment consequences associated with the AUC program during CY 2022. CMS is encouraging stakeholders to use this period to learn, test, and prepare for the AUC program. The necessary G-codes and modifiers corresponding to an AUC consultaton continue to be:
1. G-Code
Indicates the qCDSM, such as Infinix¹, that was consulted prior to placing the order.
2. Modifier
Indicates whether the order:
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adhered to AUC, did not adhere to AUC, or AUC was not applicable
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Lacked AUC consultation information
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Qualified for an exception
3. NPI
The national provider identifier of the ordering professional (the referrer).
GOOD TO KNOW
Certain qCDSM may return a score—in the form of a number (1-9) or color (red, yellow, green)—to indicate how closely the ordered exam corresponds to AUC. This is for the ordering provider's edification.
Any exceptions?
Ordering professionals are exempt from consulting and reporting AUC only under these circumstances:
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Emergency services in life-threatening situations
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Public health emergencies
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Services for an inpatient for whom payment is made under Medicare Part A, or for Medicare Advantage payments
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A hardship exception, such as natural disasters, no broadband internet, or EHR system failures.
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Advanced diagnostic imaging services furnished in hospitals under the Maryland Total Cost of Care model.
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Critical access hospitals
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Inpatients converted to outpatients
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Medicare as a secondary payer
What is RadNet's role?
RadNet will soon be ready to accept AUC information, if provided by ordering clinicians, for our 340+ imaging centers and for our hospital partnerships. Billing, services, and management will all be affected by this mandate.
The RadNet AUC team understands and can address all aspects of the law. We stand ready to assist RadNet’s referring physicians as they make adjustments to meet these new consultation requirements.
† Infinix is used here only as an example; CMS qualifies all Clinical Decision Support Mechanisms.
Frequently Asked Questions
The “MH” modifier will be reported on a Medicare claim for an order without AUC consultation information.
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.
The educational and operations testing period for the CMS AUC program has been extended through at least December 31, 2022. During that testing period, advanced imaging claims will be paid whether or not they correctly include AUC consultation information, but all ordering and rendering providers are strongly encouraged to participate.
There are three free portals offered which integrate a qCDSM that providers can use to consult AUC. These are:
CMS also has a list of many other qCDSMs which are fee-structured. Click here to go to that list.
Medicare claims must include
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the National Provider Identifier of the ordering professional.
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the G-code generated from the qualified Clinical Decision Support Mechanism that was consulted
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the modifier which states whether the ordered procedure adhered to the AUC, did not adhere, or was not applicable to the requirement.
No. Radiology reports are unaffected by AUC, with no change in lexicon or approach.
At this time AUC only applies when Medicare is the primary insurance.
Right now, nothing. There is no hard stop during the educational and operations testing period. CMS is asking ordering professionals to try to consult AUC during this time. Ordering professionals can continue with the order, however CMS has the authority to identify professionals who have outlier ordering patterns in the years subsequent to AUC going live. Professionals identified as outliers may be subject to prior authorization.
The following information is required: the patient’s age, the patient’s gender, signs and symptoms, and the test being ordered.
Yes, the non-participating ordering practice/provider will still have to perform an AUC consultation, as the claim must have AUC information attached when it is submitted to CDS.
At this time, AUC only applies to traditional Medicare Part B.
When the AUC penalty phase goes into effect, possibly as early as January 1, 2023, rendering providers will not receive payment for the procedure without a documented consult, according to the latest from CMS. The law does not mandate ordering providers strictly adhere to the AUC, just that AUC is consulted. There is no “hard stop” to the ordering process. Providers that do comply can receive Merit-Based Incentive Payment System (MIPS) and Improvement Activity points, as well as the Promoting Interoperability bonus from CMS.
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. However, CMS states that furnishing professionals may not consult AUC on behalf or in place of ordering professionals.
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.
Need more information?
Email: AskAboutAUC@RadNet.com