Next year is a learning and testing year for AUC, and there is no penalty during 2020. 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.
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:
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:
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:
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.”
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