CMS: Follow appropriate use criteria (AUC) coding for 2020 radiology services

Oct. 2, 2019 / By Barbara Aubry, RN

This has been in the works for a while: On July 26, 2019 CMS released CR Transmittal R2323OTN, Med Learn Matters number 11268 to take effect January 1, 2020 with an implementation date of January 6, 2020. This change impacts ordering and providing physicians and suppliers—anyone providing radiology services to Medicare Beneficiaries.

Services Impacted

The change impacts what CMS refers to as “advanced diagnostic imaging” which includes MRI, CT scan, PET services and nuclear medicine, specifically:

“Under this program, when an advanced imaging service is ordered for a Medicare beneficiary, the ordering professional will be required to consult a qualified Clinical Decision Support Mechanism (CDSM). 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 professional with a determination of whether that order adheres to AUC, does not adhere to AUC, or if there is no AUC applicable (for example, no AUC is
available to address the patient’s clinical condition) in the CDSM consulted.

When this program is fully implemented at a future date, a consultation must take place for any applicable imaging service ordered by an ordering professional that would be furnished in an applicable setting and paid under an applicable payment system and information related to the consultation must be appended to claims.”

CMS goes on to clarify that this applies to the “The applicable setting where the imaging service is furnished, not the setting where the imaging service is ordered. Applicable settings include:
       – Physician offices
       – Hospital outpatient departments (including emergency departments)
       – Ambulatory Surgical Centers (ASCs)
       – Independent diagnostic testing facilities

Applicable payment systems include:
       – Physician Fee Schedule (PFS)
       – Hospital Outpatient Prospective Payment System
       – ASCs

Institutional claim providers do not have the capability to report line level ordering physician information on the institutional claim at this point. CMS is working with industry partners and will provide additional instructions on reporting line level ordering physician information for institutional claims at a future date.”

My Take

This should come as no surprise since it’s been done for years by managed care plans. I’m not sure what CMS means by “a consultation must take place for any applicable imaging service ordered by an ordering professional that would be furnished in an applicable setting” since they do not reimburse for consultations. Perhaps they will create a new HCPCS code for this service? It’s not clear to me who will be responsible for providing the “consultation.”

CMS is going to test this program for a year, from January 1, 2020 to December 31, 2020, with full implementation expected in January of 2021. Emergency services, provider hardship and Part A imaging services are not subject to this program. Of interest is the fact that CMS (at least at this juncture) intends to require preauthorization of services from outlier-ordering providers by reviewing ordering patterns. However, CMS intends to allow a notification and comment interval before the prior authorization program begins.

CMS also encourages providers to begin using the new HCPCS codes created for the program during the testing period. They refer to this period as the Educational and Operations Testing Period. There are a range of M modifiers (MA-MH and QQ) that will need to be appended to claims in 2020 plus a list of G codes (G1000-G1011) that will need to be reported. If your system requires a nominal charge to be appended to these G codes, CMS will allow that, but the G codes do not have reimbursement value. The MLN Matters article includes a list of all the radiology/nuclear medicine CPT codes for the services impacted.

At this time, there seem to be more questions than answers, but at least there is a year to test the program. If you have questions, I suggest contacting CMS so your opinion is heard. This is still a work-in-progress…good luck!

Barbara Aubry is a regulatory analyst for 3M Health Information Systems.

References:

• The official instruction, CR11268, issued to MACs https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R2323OTN.pdf.
• Additional information https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/AppropriateUse-Criteria-Program/index.html.