The appropriate use criteria (AUC) program was established under The Protecting Access to Medicare Act (PAMA) of 2014 to ensure providers ordered the most appropriate advanced diagnostic imaging services for Medicare beneficiaries. Under the program, ordering providers will consult an electronic portal called a Clinical Decision Support Mechanism (CDSM) to ensure the established appropriate use criteria (AUC) for that test were met. To receive reimbursement, furnishing providers will need to apply the appropriate modifier and CDSM G-code to the claim.
The program is currently in an “educational and operations testing” phase and claims without AUC information are not being denied; however, CMS is encouraging reporting to prepare for the effective date.
Over the past several years, CMS has stepped in and delayed the implementation of this program. In June 2022, CMS announced, “The payment penalty phase will not begin January 1, 2023, even if the PHE for COVID-19 ends in 2022. Until further notice, the educational and operations testing period will continue. CMS is unable to forecast when the payment penalty phase will begin.”
Why Radiologists Need to Plan Now
For any issue, there are four stages of implementation: waiting, educating, planning, and implementing. The continuous delays have left numerous radiologists in the waiting stage, wondering why they should begin developing a process to comply with the AUC program and waiting to understand these issues once the final implementation date is announced.
However, with thousands of health systems and providers around the country needing to implement the program once in effect and only 21 CMS-qualified CDSM providers, now is the time to start preparing. In addition, this program will require a new level of coordination between the ordering and furnishing providers. Furnishing providers of the service are required to put the modifier and unique code on the claim to ensure payment and that information can only be obtained by the ordering provider.
It is unclear how much time CMS will give providers to prepare before finalizing the implementation date; therefore at a minimum, radiologists should be in the active education and planning stages to ensure their reimbursement isn’t impacted. Providers need to act now to ensure they are educated on the requirements of the program and have a plan in place to implement enhanced processes to ensure compliance once an implementation date is announced.
Before reviewing the steps providers can take today to ensure compliance, let’s first review which providers are impacted and how this program will work.
Which Providers Are Impacted?
This program impacts all physicians and providers that:
- Order advanced imaging services include computed tomography (CT), positron computed tomography (CT), positron emission tomography (PET), nuclear medicine, and magnetic resonance imaging (MRI).
- Furnish advanced imaging services in a physician’s office, hospital outpatient departments, independent diagnostic testing facilities, and ambulatory surgery centers.
- Receive reimbursement for advanced imaging services under the physician fee schedule, hospital outpatient prospective payment system, or ambulatory surgical payment system.
How Will the Program Work?
Under this program, providers ordering an advanced diagnostic imaging service for a Medicare beneficiary will be required to consult a qualified CDSM to determine if the order adheres to the AUC. Through CDSM ordering, providers will receive a unique identifier to demonstrate the consultation took place. The unique code must be applied to the claim by the furnishing provider.
Appropriate Use Criteria (AUC) – Evidence-based guidelines to assist providers in making the most appropriate and medically necessary imaging or treatment decisions for a specific clinical condition. AUC used in this program must be developed by a CMS-designated Provider Led Entity (PLE).
Clinical Decision Support Mechanism (CSDM) – An electronic portal through which ordering providers access AUC and receive a unique identifier for the furnishing provider’s claim to demonstrate the consultation occurred. The CDSM provides a determination of whether the order adheres to AUC or if the AUC consulted was not applicable (e.g., no AUC is available to address the patient’s clinical condition). A qualified CDSM module can be accessed within or through electronic health record (EHR) technology.
Claim Modifier and Code – Providers who furnish this advanced imaging must document each consultation on the CMS claim to receive reimbursement for their services, including a unique CDSM vendor G code and CMS-specified modifiers related to consultation results or, if applicable, exemptions.
Ordering vs. Furnishing Provider – The ordering provider is required to consult the CDSM and provide the code modifier to the furnishing providers to put on the claim. The radiologist and radiology staff cannot consult the CDSM for their referring provider.
What Steps Should Radiologists Take Now?
While the implementation date has again been delayed, there are simple steps radiologists can take today to ensure they are educated and have a plan in place to implement processes to meet the requirements of the AUC program when effective.
1. Identify Providers Who Order Advanced Imaging Services
Work with your billing provider to identify your top referring providers who order advanced diagnostic imaging services. This information should be grouped by top ordering providers and practices. This will allow you to identify which providers, by practice will need to access the CDSM once effective.
2. Evaluate AUC Priority Clinical Areas
Radiologists should educate themselves on the AUC and the priority clinical areas established under the AUC program.
3. Schedule a CDSM Demo
Evaluate the list of qualified CDSMs and schedule a demo on how the system will work and can be incorporated. Radiology providers need to educate themselves on the CDSM so they can, in turn, educate their referral sources and make recommendations on how to access the CDSM. Several qualified CDSM providers also have resources to assist with prior authorizations, such as the XIFIN’s partner INFINX.
4. Educate Ordering Providers and Practices
Using the information obtained from your billing solution, begin meeting with your top referrals to ensure they are educated on the issues and the potential impacts on their processes. The CDSM will need to be accessed by the ordering provider and can be incorporated into their EMR system. If the CDSM is not a module available in their current EMR, work with them to get direct access to a CDSM. The American Academy of Radiology provides several educational resources for radiology professionals.
5. Develop Plan to Modify Billing Processes
Work with your billing solution provider to identify billing processes that may need to be modified to ensure the applicable modifier and G-code is applied to all Medicare orders requiring a CDSM consult before submitting for reimbursement once the program is implemented.