CMS Releases Preliminary Reporting & Claims Processing Instructions for the Appropriate Use Criteria for Advanced Diagnostic Imaging Program in the Educational & Operations Testing Period

August 7, 2019

Starting January 1, 2020, referring providers who intend to order advanced diagnostic imaging services (ADIS) – CT, MRI, nuclear medicine exams and PET – that will be performed in outpatient settings will have to consult a qualified Clinical Decision Support Mechanism (CDSM) first.  In turn, proof of the consult and the CDSM’s determination of whether an order does or doesn’t adhere to Appropriate Use Criteria (AUC) or if there isn’t an AUC applicable (such as for a particular clinical condition), etc., will have to be included on the furnishing radiologists’ and facilities’ claims to Medicare.  Beginning January 1, 2021, Medicare will not pay for the furnishing providers’ services if the required information isn’t included on their claims.

Note:  If you missed our first white paper on this topic, Big Changes Coming for Radiologists in Regards to the Appropriate Use Mandate, please click here and take a moment to review the white paper for additional information about the Program and special considerations to keep in mind while coordinating implementation.

Let’s start with a quick run-down of the Program conditions.

• The ordering clinician or a delegated clinical staff member will perform the consult

• The consult is required when the advanced diagnostic imaging service will be performed in any of the following outpatient settings:
o Physician Office
o Hospital Outpatient – including Emergency Departments
o Ambulatory Surgical Centers
o Independent Diagnostic Testing Facilities

• The furnishing providers – the facility and the radiologist – will both have to include the AUC/CDSM information on their claims to Medicare to be paid for their services

• Certain exceptions to consulting a CDSM apply, including:
o The ordering clinician has a significant hardship, such as insufficient internet access or CDSM vendor issues
o The patient has an emergency medical condition such that the absence of immediate medical attention places him or her in jeopardy
o The applicable imaging service would be for an inpatient

• Ultimately, the Program will result in prior authorization requirements for ordering professionals that are identified as having outlier patterns, but before that begins there will be notice and comment rulemaking about the methodology that will be developed to identify outliers

• The Educational and Operations Testing Period will last one year:  January 1, 2020, through December 31, 2020, during which payment of claims is not affected

• Full Program implementation is expected January 1, 2021, at which time claims will have to reflect the CDSM consult (or appropriate exception) in order to be paid

Now, let’s look at the instructions for how the AUC-related information will be reported on your claims to Medicare.

Beginning with the testing period start of January 1, 2020, Medicare’s claims processing system will be prepared to accept claims containing:

1) The designated HCPCS modifier describing the level of adherence to AUC, or an exception to the requirement;
2) The G code identifying the qualified CDSM consulted

Please see the below PDF for the HCPCS modifiers that have been established for placement on the same line as the CPT code for the advanced imaging service.

Claims that report HCPCS modifier ME, MF or MG on the advanced diagnostic imaging CPT code claim line should additionally contain a G code (on a separate claim line) to reflect which qualified CDSM was consulted (Note: multiple G codes on a single claim is acceptable).  These G codes can be found in the below PDF.

A reminder about the timeline:

July 2018 – December 2019:  Voluntary Reporting Period – Payments not Affected
January 1, 2020 – December 31, 2020:  Educational and Operations Testing Period – Payments not Affected
January 1, 2021:  Testing Period over/Full implementation – Payments Affected

APS’ AUC Work Group will provide further information about this initiative as released by Medicare and will continue working with our clients and their facilities to integrate this requirement into the needed data transmission and workflow processes to begin the testing phase in January.
For the full CMS MedLearn Matters article (MLN number MM 11268) click here.