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Appropriate Use Criteria Update
Protecting Access to Medicare
Heard of the acronyms PAMA or CDSM? If not, please read on. On March 31, 2014, Protecting Access to Medical Act (PAMA) passed on March 31, 204 – and CMS was mandated by Congress to implement an Appropriateness Use Criteria (AUC) testing period using Clinical Decision Support Mechanisms (CDSM) beginning Jan 2020.
Due to COVID-19, the Appropriate Use Critereia (AUC) program, which was to go into effect on January 1, 2021, is now set to be fully implemented on January 1, 2022. With this extended Testing Period, Windsong is encouraging referring providers to make use of the Clinical Decision Support Mechanism (CDSM) within their EMR, or via the free CareSelect tool. This will ensure staff are well versed to eliminate issues and potential penalties beginning January 1, 2022.
Beginning Jan 1, 2022 AUC Medicare ONLY (Excluding Medicare Advantage plans) consultations with qualified Clinical Decision Support tools (CDSM) are required to occur along with reporting of consultation information on the furnishing professional and furnishing facility claim (order) for the advanced diagnostic imaging services (this includes CT, MR, Nuc Med and PET exams).
What if I don’t have the QQ modifier and G-code noted on the order?
If an exam is ordered during the testing period between Jan 1, 2020 and Dec 31, 2021 and it is determined that the exam selected is not the appropriate imaging exam, the patient can still be scanned and the rendering provider can be paid. Beginning January 1, 2022 (new deadline) practices will want to avoid penalties for non-adherence.
What is required?
- HCPCS G-code (shows that AUC was consulted) on their claims for advanced diagnostic imaging services (CT, MR, Pet, Nuclear Med) for Medicare Part B patients ONLY (excluding Advantage plans).
- HCPCS QQ Modifier will demonstrate adherence to the qualified CDSM, an interactive and electronic tool designed for use by clinicians that assists in making the most appropriate treatment decision for a patient specific to the clinical condition.
Claims that fail to have the QQ modifier and G-code after Jan 1, 2022 will not be paid.
Frequently Asked Questions
Can only the ordering provider consult the CDS?
CMS did not specify the credentials of the clinical personnel in rulemaking. When not personally performed by the ordering professional the consultation with a qualified CDS may be performed by clinical staff under the direction of the ordering professional. The individual performing the AUC consultation must have sufficient clinical knowledge to interact with the CDSM and communicate with the ordering professional.
Can a code be added on a later claim to get favorable payment?
No, the AUC consultation information must be submitted with the imaging exam claim.
Is there a free CDSM tool available?
The free CareSelect tool at https://nationaldecisionsupport.com/ is available for providers who don’t have an integrated EMR solution.
Will all advanced imaging exams require the CDS code or is it just the priority areas?
AUC consultations will be required for all advanced diagnostic imaging services (CT, MR, PET, Nuclear Medicine). In the event no AUC exists for the services, a “not applicable” modifier may be used.
How will this impact the current workflow?
The CDSM will ask for age, gender, signs and symptoms and the test being ordered. AUC are triggered off the Clinical Indication or “Reason for exam.” Based on indication, an appropriateness rating will then be generated. The referring physician will need to provide the rendering physician with the codes showing that AUC has been consulted and the level of adherence with the recommended exam.
Which exams need an Appropriateness Use Criteria Code?
CT, MRI, PET and NUCLEAR MED orders for Medicare patients will require the AUC code.
Where is the Q code entered?
The QQ Modifier is entered on the claims billing submission form.
How and where do I access the Appropriateness Use Criteria tool?
Tools may be modules within or available through certified electronic health record technology (as defined in Section 1848(o)(4) of the Act, private sector mechanisms independent from certified EMR technology or those established by CMS. Certified qualified tools can be found at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/CDSM.html.
What type of information will the providers need to supply to the imaging facility?
The healthcare provider is responsible for providing the AUC consultation information to the rendering physicians as part of the order. How the information is communicated depends on the capabilities of their EMR system. Some systems will be able to pass it through an electronic interface, while others may require the referring office to manually convey it with the order.
How will this impact the current workflow?
The CDS mechanism will ask for signs and symptoms and the test being ordered. AUC are triggered off a Clinical Indication or “Reason for exam”. Based on indication, an appropriateness score will then be generated. The referring physician will need to provide the rendering physician with the name of the CDS mechanism used and whether the result of the consultation was “adhere”, “not adhere” or “not applicable.”
The rendering physician will then place this information along with the referring physician’s NPI on the radiology claim.
For more information contact Gina at gfedele@windsongwny.com or 716.631.2500, ext. 2240 or visit https://www.acr.org/Clinical-Resources/Clinical-Decision-Support
