July 12, 2018

CMS Moves Forward with AUC/CDS January 1, 2020 Deadline

Proposes use of G-codes for claims processing

The Centers for Medicare and Medicaid Services (CMS) released the calendar year (CY) 2019 Medicare Physician Fee Schedule (MPFS) proposed rule on Thursday, July 12. Upon initial review, the ACR is pleased with several provisions within the rule. CMS has proposed claims processing instructions in order to move forward with implementation of appropriate use criteria (AUC)/clinical decision support (CDS) for all advanced diagnostic imaging services on January 1, 2020. The ACR appreciates CMS’ efforts to move forward with implementation of this important, Congressionally mandated utilization program.

Conversion Factor and CMS Overall Impact Estimates

CMS estimates a CY 2019 conversion factor of $36.0463, which reflects the 0.25 percent update specified by the Medicare Access and CHIP Reauthorization Act and a budget neutrality adjustment of -0.12 percent. Overall, this is a slight increase from the current conversion factor of $35.9996.

CMS estimates an overall impact of the MPFS proposed changes to radiology and interventional radiology to be a neutral 0 percent change, while nuclear medicine would see an aggregate decrease of 1 percent and radiation oncology and radiation therapy centers a 2 percent decrease if the provisions within the proposed rule are finalized.

There are approximately 60 new and revised radiology codes for CY 2019. In the proposed rule, compared to the AMA Relative Value Scale Update Committee (RUC) recommendations, CMS proposes to increase values for some radiology codes while decreasing values for others. Our Current Procedural Terminology (CPT®) and Relative Value Scale Update Committee (RUC) teams worked very hard to achieve accurate payment rates for these radiology services. Staff will be reviewing the rule in detail to determine why CMS decided to decrease the values for some of the radiology codes.

Appropriate Use Criteria/Clinical Decision Support

On the topic of AUC, after hearing concerns from various medical specialties societies on the readiness of the previously proposed July 1, 2019 implementation date, CMS finalized a January 1, 2020, implementation date in the 2018 final rule. This delay allows time to further develop claims processing instructions. Due to the complex nature of the AUC program, CMS finalized an “educational and operations testing period” of one year that would begin on January 1, 2020. During this period, ordering professionals will consult AUC and furnishing providers will report AUC consultation information on the claim, but CMS will continue to pay claims whether or not the correct information is included. The agency notes that this educational period will allow professionals to actively participate in the program while avoiding claims denials during the learning curve.

In the 2019 proposed rule, CMS reaffirmed the January 1, 2020 mandatory consultation date, with a one year education and operations testing period. In order to meet this deadline, CMS is again proposing use of a series of G-codes and modifier for claims processing. The agency notes that it will consider future opportunities to use a unique consultation identifier (UCI) for claims processing and will continue to engage with stakeholders on this topic.

In response to comments in the 2018 rulemaking cycle seeking clarification on who is required to perform the consultation of AUC through a qualified clinical decision support mechanism, CMS is proposing that the consultation may be performed by “clinical staff working under the direction of the ordering professional”. This allows flexibility, but still achieves the goal of the program to promote the use of AUC.

CMS is also proposing to add independent diagnostic testing facilities (IDTFs) to the definition of “applicable setting” for the AUC program. Other applicable settings include a physician’s office, a hospital outpatient department (including an emergency department) and an ambulatory surgical center. The agency believes adding IDTFs as an applicable setting “appropriately and consistently applies the AUC program across the range of outpatient settings where applicable imaging services are furnished.” CMS also invites comments on the addition of any other applicable settings for the AUC program.

With regard to significant hardship exceptions, CMS proposes that an ordering professional experiencing any of the following when ordering an advanced diagnostic imaging service would not be required to consult AUC using a qualified CDSM:

  • Insufficient internet access;
  • EHR or CDSM vendor issues; or
  • Extreme and uncontrollable circumstances (including natural or manmade disasters).

These circumstances would be self-attested and reported to the furnishing professional, who would then append an appropriate modifier indicating that the ordering professional reported a significant hardship exception.

Finally, CMS invites the public to submit ideas on a possible methodology for the identification of outlier ordering professionals for the final phase of the AUC program. The agency notes that they do not intend to use data during the education and operations testing period for determining outliers and as such, it expects to address outlier identification in 2022 or 2023 rulemaking.

Payment Rates for Nonexcepted Off-campus Provider-Based Hospital Departments Paid Under the MPFS

Section 603 of the Bipartisan Budget Act of 2015 requires that certain items and services furnished by certain off-campus hospital outpatient provider-based departments are no longer paid under the Hospital Outpatient Prospective Payment System (OPPS) beginning January 1, 2017. For CY 2018, CMS pays for these items and services under the MPFS at a rate of 40 percent of the OPPS rate. For CY 2019, CMS is proposing to maintain the current MPFS payment rates for these items and services at 40 percent of the OPPS payment rate.

Radiology Assistant Supervision

CMS is proposing to revise the physician supervision requirements so that any diagnostic test performed by a Radiologist Assistant (RA) may be furnished under, at most, a direct level of physician supervision, when performed by an RA in accordance with state law and state scope of practice rules. This is in response to stakeholder comments that the current requirement of personal supervision that applies to some diagnostic tests is overly restrictive when the test is performed by an RA, and does not allow for radiologists to make full use of RAs; and that reducing the required level of supervision will improve efficiency of care.

Additional Information

ACR staff will complete a detailed review of the proposed rule in the coming weeks. Additional information will be posted on the ACR website as it becomes available. CMS has posted a press release on their website. ACR staff will review the entire MPFS proposed rule in the coming weeks and will provide a comprehensive summary of the rule. The ACR will also submit comments to CMS by the comment period deadline on September 10th.

Please contact Katie Keysor at kkeysor@acr.org with any questions.