The Protecting Access to Medicare Act (PAMA) of 2014, Section 218(b), established a new program under which an ordering provider of advanced diagnostic imaging studies must consult a clinical decision support (CDS) mechanism at the time of ordering. The program is slated to begin on July 1, 2018. This date is the start of a voluntary participation and reporting period using a new Healthcare Common Procedure Coding System modifier, “QQ.” This article describes how billing claims will occur during this voluntary reporting period and provides background on the broader move toward full CDS implementation.
PAMA mandated CDS consultation during advanced diagnostic imaging ordering by Jan.1, 2017. CMS failed to meet that deadline; however the ACR sees the start of a voluntary reporting period as a favorable transitional step toward full implementation, which is expected by 2020. Since PAMA’s passage, several steps toward implementation have occurred, including the naming of approved provider-led entities and CDS mechanisms. The ACR has been approved as both.
Full implementation will require more information on billing claims than the QQ modifier can enable, such as the consulted CDS mechanism and the outcome of AUC consultation, including orders that are cancelled outright. In addition, outliers must be identified three years into the program, which adds another layer of complexity. The ACR, along with other stakeholders, is working with CMS on the development of appropriate billing processes.
Guidance from CMS is outlined below:
Effective July 1, 2018, HCPCS modifier QQ (ordering professional consulted a qualified clinical decision support mechanism for this service and the related data was provided to the furnishing professional) is available for this reporting. The modifier may be:
- Used when the furnishing professional is aware of the result of the ordering professional’s consultation with a CDSM for that patient,
- Reported on the same claim line as the CPT code for an advanced diagnostic imaging service furnished in an applicable setting and paid for under an applicable payment system, and,
- Reported on both the facility and professional claim.
The ACR encourages the use of the QQ modifier. For those practices that have ordering providers using a CDS mechanism and communicating the result to the radiology practices, the modifier should be appended. Reporting is voluntary, and payment is not at risk. In other words, payment will occur whether the modifier is being used properly or not. The benefit for practices is claims experience.
The benefit for the program is also important. The more billing claims that include the QQ modifier, the more CMS will see that CDS is being adopted. Conversely, limited voluntary reporting may imply that adoption of CDS is lower than expected. Moreover, the voluntary reporting could prompt a worthwhile discussion with hospitals and referring physicians regarding CDS and its implementation and expansion. For instance, under the Merit-Based Incentive Payment System, ordering providers who use a CDS mechanism can attest to a required Improvement Activity. By attesting, practices are letting CMS know that they are doing it, and no data requirement or use of the QQ modifier is necessary. Additionally in 2018, radiologists are being scored on a category called “Cost,” which judges physicians on resource use compared to other physicians. Therefore, the new QQ modifier could prompt discussions on CDS as a means to appropriately lower cost.
Even though radiologists have a ways to go before full implementation of CDS, the voluntary period is a step in the right direction. The use of the new QQ modifier will show CMS that adoption is occurring and that additional steps toward full implementation should follow. Practices may be able to leverage the use of the new modifier to prompt discussions with hospitals and referring physicians ahead of full implementation. The ACR stands ready to inform those regulations, believing that the program provides purposeful and lasting benefits (learn more at acr.org/CDS).
- CMS Medicare Learning Network. Appropriate Use Criteria for Advanced Diagnostic Imaging – Voluntary Participation and Reporting Period - Claims Processing Requirements – HCPCS Modifier QQ. Available at bit.ly/QQModifier. Published March 2, 2018. Accessed April 25, 2018.
- Silva E. Cost — Rarely Understood but Highly Relevant. ACR Bulletin, February 2018. Available at bit.ly/Cost-Relevant.