A recent communication issued by CMS in July provided some all-important billing guidance for radiology practices and others that intend to use the Appropriate Use Criteria (AUC) program test year for exactly that—to test the mechanics of implementing AUC in 2020, before penalties begin in 2021.

While CMS had outlined which studies would be applicable in which settings for Medicare patients and which technologies and appropriate use criteria were approved for use, it had yet to provide guidance for exactly how to indicate for billing purposes that AUC had been consulted and whether or not the study was recommended.

On July 26, 2019, CMS issued MLN Matters Number MM11268 advising physicians, and their billing staffs and vendors that eight new modifiers and 12 new G-codes have been introduced for use in filing claims for advanced imaging studies beginning January 1, 2020, start of the AUC program Operations and Testing Period.

On the same day, CMS issued Change Request (CR) 11268 to inform Medicare Administrative Contractors (MACs) that, effective January 1, 2020, they should accept the Appropriate Use Criteria (AUC) related HCPCS modifiers on claims.

CMS requested that providers inform billing staff and vendors of this update. The agency also advised that subsequent CRs will follow at a later date that will continue AUC program implementation.

A Brief Recap

To briefly recap, the program was authorized by the Protecting Access to Medicare Act of 2014: When an advanced imaging service is ordered for a Medicare beneficiary, the ordering professional will be required to consult a qualified Clinical Decision Support Mechanism (CDSM). The CDSM is an interactive, electronic tool that communicates AUC information to the user and assists them in making the most appropriate treatment decision for a patient’s specific clinical condition during the patient’s workup. The CDSM will issue to the ordering provider a determination of whether or not that order adheres to AUC, or if there is no applicable AUC applicable in the CDSM consulted.

This mandate applies in the following settings:

• Physician offices
• Hospital outpatient departments (including Eds)
• Ambulatory Surgical Centers
• Independent Diagnostic Testing Facilities

Applicable payment systems include MPFS, HOPPS, and ASCs.

"Next year is a learning and testing year for AUC, and there is no penalty during 2020," notes Lisa Mead, RN, MS, CPHQ, CHPC, executive director, Strategic Radiology Patient Safety Organization. "Our practices are currently working with their hospital partners and referring providers to educate them on the requirements. Ideally the industry is prepared to be testing January 1, but we will see many people just getting started."

HCPCS Modifiers and G-codes

Eight new Healthcare Common Procedure Coding System (HCPCS) modifier codes have been developed beyond the single QQ code to describe every possible outcome of the interaction with the CDSM—from ordering professional not required to consult CDSM for a variety of reasons to CDSM consulted and order adheres to AUC. Sites billing for relevant advanced imaging procedures performed on Medicare patients are requested to enter one of the following HCPCS codes on the same line where the CPT code is entered:

• 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 and the related data was provided to the furnishing professional

CMS also requests that one of the following 12 G-codes be entered on a separate claim line for applicable advanced medical imaging studies to indicate which CDSM was consulted:

• G1000–Clinical Decision Support Mechanism Applied Pathways, as defined by the Medicare Appropriate Use Criteria Program
• G1001–Clinical Decision Support Mechanism eviCore, as defined by the Medicare Appropriate Use Criteria Program
•  G1002–Clinical Decision Support Mechanism MedCurrent, as defined by the Medicare Appropriate Use Criteria Program
• G1003–Clinical Decision Support Mechanism Medicalis, as defined by the Medicare Appropriate Use Criteria Program
• G1004–Clinical Decision Support Mechanism National Decision Support Company, as defined by the Medicare Appropriate Use Criteria Program
• G1005–Clinical Decision Support Mechanism National Imaging Associates, as defined by the Medicare Appropriate Use Criteria Program
• G1006–Clinical Decision Support Mechanism Test Appropriate, as defined by the Medicare Appropriate Use Criteria Program
• G1007–Clinical Decision Support Mechanism AIM Specialty Health, as defined by the Medicare Appropriate Use Criteria Program
• G1008–Clinical Decision Support Mechanism Cranberry Peak, as defined by the Medicare Appropriate Use Criteria Program
• G1009–Clinical Decision Support Mechanism Sage Health Management Solutions, as defined by the Medicare Appropriate Use Criteria Program
• G1010–Clinical Decision Support Mechanism Stanson, as defined by the Medicare Appropriate Use Criteria Program 
• G1011–Clinical Decision Support Mechanism, qualified tool not otherwise specified, as defined by the Medicare Appropriate Use Criteria Program

Writing in the ACR Bulletin, Ezequiel Silva III, MD, FACR, Chair, Commission on Economics, ACR, suggests that the guidance is evidence of CMS’s commitment to move forward with the AUC program “The transmittals confirm CMS’s commitment to advancing this program — motivating radiology professionals to explore and implement the program,” he wrote, adding: “Payments are not at risk in 2020, providing time for education and testing before full implementation in just over a year.”