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) has established that 2020 will be an educational and testing period for the Medicare AUC program.
RadNet will be ready to accept AUC information during the 2020 educational and testing period.
What’s the latest?
No Medicare claims for advanced imaging will be denied for lack of AUC information. But CMS is encouraging ordering and rendering providers to participate in the program by publishing the necessary G-codes and modifiers corresponding to an AUC consultaton:
1. G-Code
Indicates the qCDSM, such as NDSC’s CareSelect¹, 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
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.
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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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.
What is RadNet's role?
RadNet's AUC team is ready to accept AUC information, if provided by ordering clinicians, for our 300+ 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.
† National Decision Support Company’s CareSelect is used here only as an example; CMS qualifies all Clinical Decision Support Mechanisms.
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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 is scheduled to begin on January 1, 2020. 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 four free portals offered which integrate a qCDSM that providers can use to consult AUC. These are:
CMS Also has a list of 14 other qCDSM’s 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 in 2020, as it is an operational and testing year. CMS is asking ordering professionals to try to consult AUC during the educational and testing year. 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.
Staring January 1, 2021, rendering providers will not receive payment for the procedure without a documented consult. 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.
No, the mandate states that the ordering professional must perform the AUC 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.
