The Centers for Medicare and Medicaid Services (CMS) is now requiring the use of Appropriate Use Criteria (AUC) for all providers ordering advanced diagnostic imaging services for Medicare B patients. The goal of this new program is to ensure that, moving forward, the most appropriate testing is ordered for Medicare B patients.
A procedure is considered “appropriate” when the expected health benefits exceed the expected health risks by a wide margin.
AUC is the criteria by which the CMS determines whether a diagnostic imaging service has been appropriately ordered. Decisions are based on a rating scale of 1-9, with ratings between 4-9 being considered appropriate.
AUC is required for any practitioner ordering the following advanced diagnostic imaging services for patients covered under Medicare B:
- MRI (Magnetic Resonance Imaging)
- CT (Computed Tomography)
- PET (Positron Emission Tomography)
- Nuclear Medicine
CDS-clinical decision support
CDSM-clinical decision support mechanism
AUC documentation-modifiers and G-codes that represent compliance with the program
01/01/2020-12/31/2021–Operations and testing period
- CMS will deny claims that do not have AUC documentation
If you are ordering one of the procedures listed above for a patient covered under Medicare Part B, you must first consult a qualified CDSM before the patient is scheduled. It is possible that your EHR (Electronic Health Record) is already pulling this info in for you and linking to a qualified CDSM. Keep a record of the DSN (Decision Support Number) and the Appropriateness Score, in case you need to refer back to that information.
The CDSM will indicate if the imaging service adheres to the AUC, does not adhere, or there is no applicable AUC. If it does not adhere, the practitioner must make a decision about ordering a different imaging service or proceed with the service despite it not adhering to the AUC.
If you are in the position of choosing which CDSM to reference, make note of which tool you consulted. When placing the order for the imaging service, you will be required to provide the name of the CDSM consulted and the AUC response, so that we can appropriately conduct the imaging study for the patient.
ADR will report this information on the patient’s claim using a “G” code for the CDSM and a modifier will indicate whether or not the study adheres to the AUC.
The 5 W's of AUC/CDS
- Physician’s office
- Hospital Outpatient Department (Including the Emergency Department)
- Ambulatory Surgical Center
- Independent Diagnostic Testing Facility
Applicable Payment System
- Physician Fee schedule
- Hospital Outpatient Prospective Payment System
- Ambulatory Surgical Center Payment System
CAH are exempt from CDS program at this time.
Any practitioner, or clinical staff member is required to consult a CDSM when ordering advanced diagnostic imaging for a Medicare beneficiary in an outpatient setting.
ADR can NOT consult a CDSM on behalf of an ordering provider.
Consultation of a CDSM is required for ordering advanced imaging studies for Medicare beneficiaries in the applicable settings and under the applicable payment systems
Consultation is NOT required in the case of the following hardship exceptions:
- A suspected of confirmed emergency condition
- Insufficient internet access
- EHR or CDSM vendor issues
- Extreme and uncontrollable circumstances
These situations ARE required to be documented through use of a modifier
In order to pay claims, CMS requires:
- NPI of the ordering provider
- AUC Modifier-shows the outcome of consulting the CDSM or documents why a CDSM is not consulted
G-Code– code that corresponds to the specific CDSM that was consulted
Not required but may be useful:
- DSN-Decision Support Number – unique number generated by the CDSM
- Appropriateness Score – rating of how appropriate the order is on a scale of 1-9
The purpose of the program is to identify patterns of ordering physicians and reduce the amount of inappropriate imaging tests performed on beneficiaries.
Studies have shown that consulting AUC helps ensure quality and cost-effective patient care.