Starting last January, Medicare required ordering providers to consult appropriate use criteria (AUC) via an electronic clinical decision support (CDS) tool when ordering outpatient advanced imaging exams.
However, this first year was considered an education and testing year, which meant there would be no reimbursement denials for failure to comply with the mandate.
This past week, CMS announced that it was extending this education and testing year through calendar year 2021. This should be welcome news to many imaging programs, as Covid-19 has hurt department finances and halted implementation and pilots. Reimbursement denials for furnishing providers who do not document AUC consultation will now begin Jan. 1, 2022.
First, a brief refresher on CDS
In the Protecting Access to Medicare Act (PAMA) of 2014, Congress included a mandate for ordering providers to consult AUC via electronic CDS when ordering outpatient advanced imaging exams for Medicare fee-for-service beneficiaries. Furnishing providers—most commonly radiologists and imaging programs—must document that consultation for reimbursement.
Next, six things to know about the AUC program
1. Education and testing period began Jan. 1, 2020
Though the program began in 2020, the first two years have now been deemed an "educational and testing" period, meaning claims will be paid regardless of documentation. Beginning Jan. 1, 2022, Medicare will deny claims that do not include necessary information (more on documentation below). During the educational and testing period, providers may use the modifier QQ during the voluntary reporting period already underway.
Guidance for providers: Although claims will not be denied until 2022, CDS consultation is mandatory. Organizations should develop an implementation strategy now to allow time to test the product, educate and train ordering providers, and slowly roll out the tool across the health system. Encourage ordering providers to participate in voluntary reporting, and emphasize the potential to earn MIPS credit as a benefit to early adoption. Use our tools and resources designed to help imaging leaders throughout the implementation process.
2. Furnishing providers must use G-codes and modifiers to document consultation
Ordering providers consult CDS, but furnishing providers are responsible for reporting that consultation took place. This claims-based reporting must include three separate items:
- G-codes: CDSM consulted;
- Modifiers: AUC adherence (adherent, not adherent, or not applicable); and
- NPI: National provider identification (NPI) of the ordering professional.
Last year, the agency released the specific codes to use. Review our coding guide so that you're prepared for the end of the education and testing period.
Guidance for providers: Radiologists and imaging programs are financially responsible for documenting CDS consultation. Now that CMS has released the exact G-codes and modifiers required, imaging leaders should start working with their informatics team and CDS vendors to incorporate these into claims. For more information on how to ensure CDS adherence, review section three of our toolkit.
3. Ordering providers or their clinical staff can consult CDS
Currently, two groups can consult CDS:
- Ordering professional: A physician or practitioner who orders the imaging service; and
- Clinical staff: An individual working under the direction of the ordering provider. This staff member must have sufficient clinical knowledge to consult CDS and communicate results back to the ordering professional.
CMS will allow clinical staff to consult CDS on behalf of ordering providers to ease reporting requirements. Importantly, this only applies to staff within the ordering provider's office and does not include radiology staff or radiologists.
Keep in mind that the ordering professional's NPI will be recorded on the imaging claim, even if a clinical staff member consulted CDS. The ordering professional is responsible for correct consultation; the NPI will be used to identify outlier ordering providers subject to Medicare prior authorization, which will begin as early as 2023.
Guidance for providers: Now that more individuals are able to consult CDS, imaging leaders must expand education efforts to this new cohort. Review section one of our toolkit for resources to guide your education strategy.
4. CDS required for imaging provided at all outpatient sites
CDS consultation will be required when imaging is provided in the following outpatient care settings:
- Physician offices;
- Hospital outpatient departments (including non-emergency conditions in the ED);
- Ambulatory surgery centers; and
- Independent Diagnostic Testing Facilities (IDTFs)
Guidance for providers: The inclusion of all outpatient settings equalizes the playing field for imaging providers. To differentiate yourself in the market, radiology programs should identify ways to streamline CDS consultation and documentation.
5. Hardship exemptions available if needed
CMS finalized four hardship exemptions and the associated reporting mechanism. These are in addition to inpatient services. Those service are exempt since this mandate only applies to Medicare Part B.
Specifically, ordering providers, not furnishing providers, will be exempt from consulting CDS if they experience:
Guidance for providers: Imaging leaders should educate ordering providers on all CDS requirements and exemptions. Ultimately imaging's reimbursement is at-risk if the ordering provider cannot consult CDS and doesn't claim an exemption.
6. Outlier identification to-be-determined, but will penalize noncompliant ordering providers
Up to 5% of ordering providers will be identified as outliers and required to obtain preauthorization when ordering imaging for Medicare patients.
In the 2019 rulemaking cycle, CMS requested public feedback on creating the methodology for outlier identification, particularly around the required data elements and thresholds. CMS will address this further in the 2022 or 2023 rulemaking cycles. We do know that adherence to AUC within eight priority clinical areas will be considered. For more information on the finalized priority clinical areas, read our 2017 analysis.
Guidance for providers: While imaging's reimbursement is at-risk, the outlier classification and required preauthorization is one mechanism to hold ordering providers accountable for appropriate CDS consultation. Stress the potential for Medicare prior authorization when providing CDS education to these professionals. For more information on talking points, refer to section one of our toolkit.
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