APPROPRIATE USE CRITERIA (AUC) PROGRAM FOR ADVANCED DIAGNOSTIC IMAGING SERVICES…THE NEXT BIG CMS REQUIREMENT IS FORTHCOMING AND EFFECTIVE JANUARY 1, 2022

PURPOSE:

• Promote the ordering of the most appropriate test for the patient using evidence-based criteria;
• Utilize data collected to identify outlier ordering providers who will become subject to CMS prior authorization for advanced diagnostic imaging services.

TESTING PERIOD:

For the past 18+ months, the AUC Program educational and operational testing period has been underway.  As of January 1, 2020, CMS began accepting AUC-related modifiers on claims for advanced diagnostic imaging services provided to Medicare beneficiaries. This testing period was established in preparation for full AUC Program implementation planned for January 1, 2022, which is right around the corner. Once implemented, hospitals and other outpatient providers will be at risk of claims denials for failing to include the AUC-related information on applicable outpatient claims or for misreporting AUC information on non-qualifying services and related claims.

TESTS SUBJECT TO THE REQUIREMENTS:

The specific CPT/HCPCS codes subject to the program are available in a CMS MLN Matters article linked here: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11268.pdf

AUC PROGRAM PROCESS SUMMARIZED:

• Ordering provider is required to consult a qualified CDSM (Clinical Decision Support Mechanism) and provide information to the furnishing test provider for reporting required information on their claims. Per Novitas Solutions, “a CDSM is an interactive, electronic tool for use by clinicians 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 provide the ordering provider with a determination of whether that order:
  • Adheres to AUC;
  • Does not adhere to AUC; or
  • No applicable AUC exists
• Who does the AUC Program apply to?
  • Physician Offices
  • Hospital Outpatient Departments including Emergency Departments
  • ASCs
  • Independent Diagnostic Testing Facility (IDTF)
  • Any other provider-led outpatient setting
• Medicare payment systems applicable to ACU: Physician Fee Schedule, OPPS, and ASC

EXCEPTIONS TO AUC PARTICIPATION:

• Ordering professionals under significant hardship
• Patient with a medical emergency condition
• Inpatient Imaging Services

CLAIMS REPORTING REQUIREMENTS:

• CPT/HCPCS code for the advanced imaging service
• AUC Modifier for the CPT/HCPCS service line [see AUC Modifier table below]
• Line Item G-code to identify the qualified CDSM consulted:
  • Report a separate line when using modifiers ME, MF, or MG
  • Report with a nominal charge (e.g., $0.01)
  • Multiple G-codes can be reported on a single claim
  • For reporting purposes only; no payment on CDSM G-codes

*CMS CDSM LIST: Clinical Decision Support Mechanisms | CMS

AUC MODIFIERS LIST [per Novitas Medicare website]:

References:

Novitas Solutions Medicare JL: Article on Appropriate Use Criteria (AUC) Program for Advanced Imaging Services: Appropriate use criteria (AUC) program for advanced diagnostic imaging services (novitas-solutions.com)

AUC for Advanced Diagnostic Imaging- Approval of Using the K3 Segment for Institutional Claims

https://www.cms.gov/files/document/se20002.pdf

CMS website:  Clinical Decision Support Mechanisms | CMS