Reporting appropriate use criteria in claims for Medicare patients

The Centers for Medicare & Medicaid Services (CMS) began implementing the appropriate use criteria (AUC) program on Jan. 1, 2020 with an education and operations testing period during which physicians will continue to be paid regardless of whether AUC requirements are met. CMS recently announced the education and operations testing period has been extended through calendar year 2021. 

During 2020 and 2021, physicians and other qualified health professionals are encouraged to prepare to consult AUC when ordering advanced diagnostic imaging services for Medicare patients and to report specific data in the claim once the imaging service is performed.

While the AMA works to prepare physicians for the AUC program, we continue to call on CMS to delay mandatory implementation until technical and workflow challenges with implementation are addressed and burdensome duplication between the Quality Payment Program (QPP) and the use of advanced diagnostic AUC is resolved.

Once the program is fully implemented, which is expected to be Jan. 1, 2022, claims will be paid only if the appropriate AUC data is reported.

The AUC program was authorized by the Protecting Access to Medicare Act of 2014 (PAMA) to promote the use of AUC and decrease the number of inappropriate advanced diagnostic imaging services provided to Medicare beneficiaries. With the AUC program, the physician or clinical staff, acting at the physician’s direction, ordering the advanced diagnostic imaging service will be presented with information about the appropriateness of it based on the patient’s clinical condition. The goal is to order and provide the advanced diagnostic imaging service most likely to improve the health outcome of the patient.

The AUC requirements apply to advanced diagnostic imaging services provided in physician offices; hospital outpatient departments, including emergency departments; ambulatory surgical centers; and independent diagnostic testing facilities.

The AUC are evidence-based guidelines for specific clinical scenarios and presenting symptoms or condition. The AUC were developed by provider-led entities (PLE), which were qualified by CMS. PLEs can be national professional medical societies, health systems, hospitals, clinical practices and collaborations.

The first list of qualified PLEs was posted to the CMS website in June 2016 and the list continues to be updated.

Ordering physicians will consult the AUC using a clinical decision support mechanism (CDSM). Clinical staff, acting at the physician’s direction, are also able to complete the CDSM query. The CDSM is an interactive, electronic tool that is either stand-alone or integrated into an electronic health record (EHR). When queried, it provides a response indicating that the advanced diagnostic imaging service is appropriate, not appropriate or not applicable for the patient.

The first list of qualified CDSMs was posted to the CMS website in July 2017. The current list is available on the CMS website.

After the physician has consulted the CDSM and ordered the advanced diagnostic imaging service, the following data will have to be sent with the order to the provider completing the imaging service:

• The CDSM consulted by the ordering physician.
• Whether the service adhered to the applicable AUC, did not adhere to the applicable AUC, or whether no criteria in the CDSM were applicable to the patient’s clinical scenario.
• The National Provider Identifier (NPI) of the ordering physician.

To report the CDSM that was queried, CMS has created Healthcare Common Procedure Coding System (HCPCS) G-codes for each qualified CDSM. The identifying HCPCS code will be reported in the claim as a separate service line, in addition to the procedure code identifying the imaging service performed.

HCPCS modifiers have also been created to identify the response received by the CDSM or the applicable exception. The modifier will be reported on the same service line as the procedure code for the imaging service.

CMS released an MLN Matters article in July 2019 that includes the HCPCS codes for the CDSMs and modifiers.

Exceptions

There are a few exceptions to the requirement to consult the CDSM, which are:

• Emergencies
• Inpatient advanced diagnostic imaging services
• Ordering physician meets hardship exception

Hardship exceptions include:

• Insufficient internet access
• EHR or CDSM vendor issues
• Extreme and uncontrollable circumstances

If an exception exists, the physician will include it with the order and the furnishing physician will report the corresponding modifier on the claim. 

AUC workflow

The following is the workflow for meeting the AUC requirements:

• The physician sees a patient who is a Medicare beneficiary and plans to order an advanced diagnostic imaging service. 

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• The physician, or clinical staff under the direction of the physician, consults the AUC for the proposed advanced diagnostic imaging service through a CDSM. (The CDSM will either be integrated into the EHR or a separate portal.) If a hardship exception exists, the physician will include it with the order.
• The CDSM will search for and present the AUC relevant to the patient’s condition.
• The CDSM response will indicate if the proposed advanced diagnostic imaging service adheres to the AUC, does not adhere to the AUC, or if there is no applicable AUC.
  • If it adheres to the AUC, the physician will proceed with the order.
  • If it does not adhere, the physician must make a decision about ordering a different imaging service or proceeding with the proposed service despite it not adhering to the AUC.
• The physician orders the advanced diagnostic imaging service and includes with the order the CDSM queried, AUC response, and their NPI.
• The rendering provider furnishes the imaging service to the patient.
• The rendering provider reports in the professional and institutional claims the CDSM HCPCS G-code, the AUC modifier and the ordering physician’s NPI, in addition to the typical claim information.

The outcome of this program will be to analyze the ordering practices of the physicians and determine any outliers. PAMA calls for identification on an annual basis of no more than five percent of the total number of ordering physicians who are outliers. The use of two years of data is required for this analysis. Data collected during the 2020 education and testing period will not be used when identifying outliers.

Outliers will be determined based on low adherence to applicable AUC or comparison to other ordering physicians. Physicians who are found to be outliers will be required to complete prior authorizations for advanced diagnostic imaging services.

The following priority clinical areas will be the focus of the analysis of outliers:

• Coronary artery disease (suspected or diagnosed)
• Suspected pulmonary embolism
• Headache (traumatic and non-traumatic)
• Hip pain
• Low back pain
• Shoulder pain (to include suspected rotator cuff injury)
• Cancer of the lung (primary or metastatic, suspected or diagnosed)
• Cervical or neck pain

• Appropriate use criteria (AUC) for advanced diagnostic imaging – Fact sheet
• Appropriate use criteria (AUC) for advanced diagnostic imaging – Educational and operations testing period – Claims processing requirements (MM11268
• Appropriate use criteria (AUC) for advanced diagnostic imaging – Educational and operations testing period – Claims processing requirements (CR11268, Transmittal 2323)