The Protecting Access to Medicare Act
The Protecting Access to Medicare Act requires that physicians ordering advanced imaging exams consult Appropriate Use Criteria (AUC) through a qualified Clinical Decision Support Mechanism (qCDSM).
A Comprehensive AUC Consultation Requirement
The Protecting Access to Medicare Act requires that physicians ordering advanced imaging exams consult Appropriate Use Criteria (AUC) through a qualified Clinical Decision Support Mechanism (qCDSM).
Ordering providers are required to consult AUC for all Medicare Part B Advanced Diagnostic Imaging Services (CT, MR, NM, PET).
Consultation is required in all applicable settings as outlined by CMS. These include physician offices, hospital outpatient departments (including emergency departments), ambulatory surgical centers, and independent diagnostic testing facilities.
Program Timeline
Program Start
January 1, 2020 marks the formal start of the program. Healthcare providers will be required consult a qualified CDSM when ordering advanced imaging tests.
Education & Testing Period
Throughout 2020, the program will operate in an “Educational and Operations Testing Period”. During this period, AUC consultation must occur across all advanced imaging and AUC consultation information is expected to be reported on claims.
Payment at Risk
In January 2021 the program will be fully implemented. Information regarding the ordering professional’s consultation with a CDSM must be appended to the claim in order for that claim to be paid.
Priority Clinical Areas & Physician Measurement
CMS has outlined eight Priority Clinical Areas (PCAs) as a baseline of clinical coverage to measure outlier physicians. Outlier calculation will be based on both AUC adherence within the PCAs and applicability of the AUC to the service.
In addition to outlier calculation, the PCAs can serve as a guide to begin your CareSelect Imaging implementation. With a focus on quality improvement opportunities, the PCAs offer a springboard to create immediate impact to address imaging over-utilization.
- 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
What Information is Required on the Claim?
CMS will accept all consultation data, as defined by the regulation, in the form of G-Codes with Healthcare Common Procedure Coding System (HCPCS) modifiers. The G-code will be used to define the qCDSM ID and CPT will be amended with HCPCS modifiers to indicate pertinent AUC consultation data.
The defined information is as follows:
- Information about which qCDSM was consulted by the ordering professional for the service.
- Information regarding—
- whether the service ordered adheres to the applicable appropriate use criteria;
- whether the service ordered does not adhere to such criteria; or
- whether such criteria is not applicable to the service ordered.
- The NPI of the ordering professional
All claims will require CPT codes appended with the appropriate HCPCS modifier and G-Codes that indicate which CDSM was consulted to qualify for payment.
Qualified CDSMs have been assigned a G-code that is specific to each mechanism. CMS has created eight new HCPCS modifiers to indicate the outcome of the AUC consultation. These modifiers fall into 2 categories: (1) When an AUC is consulted or (2) When a CDSM is not consulted, for instance due to hardship.
In addition to the G-code/HCPCS modifier structure, CareSelect Imaging produces a Unique Consultation Identifier (UCI) or Decision Support Number (DSN). While the DSN is not required for claims purposes, it provides a valuable link between consultation and claims data. This is particularly important when the ordering and furnishing facilities are disparate domains. CareSelect retains this information for 6 years.
CMS Transmittal 2323
Exemptions
CMS has finalized three circumstances where ordering providers are not required to consult AUC.
These have been defined as:
- Emergency Services**
- If the service is furnished under Medicare Part A
- Hardship
This 2019 final rule clarifies the proposed hardship exclusion and makes the ordering provider ‘self-report’ their exclusion from criteria. 2019 rule-making finalized a definition for “Hardship” as:
- Insufficient internet access.
- EHR or CDSM vendor issues
- Extreme and uncontrollable circumstances
These criteria add to the existing emergency services exclusion, where consultation is not required if it will cause undue harm to the patient.
This 2019 rule finalizes the proposal for ordering professionals experiencing a significant hardship to self-attest and include that information on the order. The furnishing professional or facility would communicate on the Medicare claim for the service by appending a HCPCS modifier identifying the ordering professional’s self-attested significant hardship category.
PAMA - Additional Resources
Medicare Learning Network Fact Sheet
Appropriate Use Criteria for Advanced Imaging
Beginning in 2020, if you order Medicare Part B advanced diagnostic imaging services, you must consult appropriate use criteria (AUC) through a qualified Clinical Decision Support Mechanism (CDSM). You must also provide the information to furnishing professionals and facilities, because they must report AUC consultation information on their Medicare claims.
Download the Fact Sheet
Medicare Learning Network Matters®
Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging – Educational and Operations Testing Period - Claims Processing Requirements
CR11268 informs MACs that, effective on January 1, 2020 (the start of the AUC program Educational and Operations Testing Period), they should accept the Appropriate Use Criteria (AUC) related HCPCS modifiers on claims. Please be sure your billing staff and vendors are aware of this update.
Download the Claims Update
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* The following roles are defined as Ordering Professional by the statute.
(i) A physician assistant, nurse practitioner, or clinical nurse specialist
(ii) A certified registered nurse anesthetist
(iii) A certified nurse-midwife
(iv) A clinical social worker
(v) A clinical psychologist
(vi) A registered dietitian or nutrition professional.
** Emergency Services have been defined in Section 1867 of the Social Security Act:
The term “emergency medical condition” means:
- a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in —
- placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy,
- serious impairment to bodily functions, or
- serious dysfunction of any bodily organ or part; or
- with respect to a pregnant woman who is having contractions —
- that there is inadequate time to affect a safe transfer to another hospital before delivery, or
- that transfer may pose a threat to the health or safety of the woman or the unborn child.
