Advocacy Center   |   Collaborate   |   Data Portal   |   Print Page   |   Contact Us   |   Sign In   |   Join AAOE
News & Press: Government Affairs News

CMS Releases Details of New AUC Program

Wednesday, July 31, 2019   (0 Comments)
Posted by: Bradley Coffey, MA, O-CHCP, AAOE Government Affair
Share |

Baltimore, MD - The Centers for Medicare and Medicaid Services (CMS) has released new information about the mandatory Appropriate Use Criteria program for advanced imaging, set to begin on January 1, 2020. The program is required by law, having been passed by the Protecting Access to Medicare Act of 2014 and targets computed tomography (CT), positron emission tomography (PET), nuclear medicine, and magnetic resonance imaging (MRI).

Under this program, when an advanced imaging service is ordered, the ordering professional will be required to consult a qualified clinical decision support mechanism (CDSM). This is an interactive, electronic tool that communicates whether advanced imaging is appropriate for a given patient. Beginning on January 1, 2020 ordering professionals are required to consult a qualified CDSM and notate that consultation in the claim for the imaging service. For the 2020 payment year, CMS will not penalize providers who do not include the CDSM modifiers on a claim but will deny claims excluding the modifiers beginning in 2021.

Professionals furnishing imaging services in physician offices, hospital outpatient departments (including emergency departments), ASCs, and independent diagnostic testing facilities are affected by this program.

Starting January 1, 2020, an ordering professional must consult a qualified CDSM when ordering advanced imaging services. The ordering provider must submit a CDSM modifier to the furnishing professional who will then include the modifier on the imaging claim. The following modifiers have been developed by CMS for the AUC program and should be placed on the same claim line as the CPT code (HCPCS C code) for the advanced imaging service:

  • MA - Ordering professional is not required to consult a clinical decision support mechanism due to service being rendered to a patient with a suspected or confirmed emergency medical condition.
  • MB - Ordering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of insufficient internet access.
  • MC - Ordering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of electronic health record or clinical decision support mechanism vendor issues.
  • MD - Ordering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of extreme and uncontrollable circumstances.
  • ME - The order for this service adheres to the appropriate use criteria in the clinical decision support mechanism consulted by the ordering professional.
  • MF - The order for this service does not adhere to the appropriate use criteria in the qualified clinical decision support mechanism consulted by the ordering professional.
  • MG - The order for this service does not have appropriate use criteria in the clinical decision support mechanism consulted by the ordering professional.
  • MH - Unknown if ordering professional consulted a clinical decision support mechanism for this service, related information was not provided to the furnishing professional or provider.
  • QQ - Ordering professional consulted a qualified clinical decision support mechanism for this service and the related data was provided to the furnishing professional.

Additionally, the ordering professional should provide one of the following G-codes to indicate which qualified CDSM was consulted. The furnishing professional would then include this code(s) on a separate, dedicated line for the claim:

  • G1000 - Clinical Decision Support Mechanism Applied Pathways, as defined by the Medicare Appropriate Use Criteria Program.
  • G1001 - Clinical Decision Support Mechanism eviCore, as defined by the Medicare Appropriate Use Criteria Program
  • G1002 - Clinical Decision Support Mechanism MedCurrent, as defined by the Medicare Appropriate Use Criteria Program.
  • G1003 - Clinical Decision Support Mechanism Medicalis, as defined by the Medicare Appropriate Use Criteria Program.
  • G1004 - Clinical Decision Support Mechanism National Decision Support Company, as defined by the Medicare Appropriate Use Criteria Program.
  • G1005 - Clinical Decision Support Mechanism National Imaging Associates, as defined by the Medicare Appropriate Use Criteria Program.
  • G1006 - Clinical Decision Support Mechanism Test Appropriate, as defined by the Medicare Appropriate Use Criteria Program.
  • G1007 - Clinical Decision Support Mechanism AIM Specialty Health, as defined by the Medicare Appropriate Use Criteria Program.
  • G1008 - Clinical Decision Support Mechanism Cranberry Peak, as defined by the Medicare Appropriate Use Criteria Program.
  • G1009 - Clinical Decision Support Mechanism Sage Health Management Solutions, as defined by the Medicare Appropriate Use Criteria Program.
  • G1010 - Clinical Decision Support Mechanism Stanson, as defined by the Medicare Appropriate Use Criteria Program.
  • G1011 - Clinical Decision Support Mechanism, qualified tool not otherwise specified, as defined by the Medicare Appropriate Use Criteria Program.

Additional information will be forthcoming and you can read more in-depth instructions in this article from the Medicare Learning Network. Concerned about this program? Join us on September 9th and 10th for AAOE's Compliance Symposium and Capitol Hill Day and tell Congress this policy must change!


Membership Management Software Powered by YourMembership  ::  Legal