August 01, 2019

CMS Releases Appropriate Use Criteria Claims Processing Instructions

On July 26, 2019, the Centers for Medicare and Medicaid Services (CMS) released Appropriate Use Criteria (AUC) claims processing requirements to Medicare Administrative Contractors (MACs) via Change Request 11268 and to physicians, providers and suppliers billing Medicare MACs via a Medicare Learning Network Matters article.

The Educational and Operations Testing Period for the mandatory use of AUC when ordering advanced diagnostic imaging procedures starts January 1, 2020. CMS expects ordering professionals (OP) to consult qualified clinical decision support mechanisms (CDSMs) and provide the information to the furnishing providers to report on their claims. During this testing period, claims will not be denied if the furnishing providers fail to include the AUC-related information or do not report the AUC information correctly. However, CMS encourages inclusion because it is important for them to track this information.

Full program implementation is expected January 1, 2021. In order for the furnishing providers to get paid, they must include the ordering professional’s AUC consult or exception to the consult information on the claims. Furnishing providers are strongly encouraged to participate during the 2020 testing period and to implement the program.

Modifiers

Eight new modifiers for placement on the same line as the CPT code:

CDSM not consulted due to significant hardship
MB: OP is not required to consult a CDSM due to the significant hardship exception of insufficient internet access
MC: OP is not required to consult a CDSM due to the significant hardship exception of electronic health record or CDSM vendor issues
MD: OP is not required to consult a CDSM due to the significant hardship exception of extreme and uncontrollable circumstances

CDSM not consulted due to emergency condition
MA: OP is not required to consult a CDSM due to service being rendered to a patient with a suspected or confirmed emergency medical condition

CDSM consulted
ME: The order for this service adheres to the appropriate use criteria in the CDSM consulted by the OP
MF: The order for this service does not adhere to the AUC in the qualified CDSM consulted by the OP
MG: The order for this service does not have AUC in the CDSM consulted by the OP

Unknown if CDSM consulted
MH: Unknown if OP consulted a CDSM for this service, related information was not provided to the furnishing professional or provider

G Codes

Eleven CMS-approved qualified CDSM with its own G code. Plus G1011 (qualified tool not otherwise specified).

If modifier ME, MF or MG is reported, the claim should also contain a G code on a separate claim line to report which qualified CDSM was consulted. Multiple G codes on a single claim are acceptable.

G1000: CDSM Applied Pathways
G1001: CDSM eviCore
G1002: CDSM MedCurrent
G1003: CDSM Medicalis
G1004: CDSM National Decision Support Company
G1005: CDSM National Imaging Associates
G1006: CDSM Test Appropriate
G1007: CDSM AIM Specialty Health
G1008: CDSM Cranberry Peak
G1009: CDSM Sage Health Management Solutions
G1010: CDSM Stanson
G1011: CDSM, qualified tool not otherwise specified

CMS also notes that G codes do not have associated payment rates (e.g., they are not payable codes and are only used for reporting). MACs are expected to appropriately adjudicate these claims with CARC 246 and RARC N620 Alert.

CARC 246: This non-payable code is for required reporting only.
RARC N620 Alert: This procedure code is for quality reporting/informational purposes only.

CMS states that a subsequent Change Request will follow at a later date that will further operationalize this AUC policy.

Please direct your questions to Angela Kim, ACR senior director of economics and health policy.