New Information Regarding Appropriate Use Criteria is Released

This year, key information regarding the Appropriate Use Criteria (AUC) program is being released by the Centers for Medicare & Medicaid Services (CMS) via guidance documents. A Change Request was issued July 26, 2019, informing Medicare Administrative Contractors (MACs) that they are to begin accepting AUC-related modifiers and healthcare common procedure coding system (HCPCS) codes in 2020.

Under the AUC program, a practitioner must consult a qualified Clinical Decision Support Mechanism (qCDSM) at the time of an advanced diagnostic imaging service order. The qCDSM – an electronic portal through which AUC is accessed – provides a determination of whether the order adheres to AUC or if the AUC consulted was not applicable to the patient’s clinical condition.

Currently running as a voluntary program, CMS has announced an Education and Operations Testing Period to begin January 1, 2020 and running the full calendar year to give practitioners appropriate time to adjust to the system. During this period, “claims will not be denied for failing to include AUC-related information or for misreporting AUC information.” However, CMS also writes that they expect ordering professionals to begin consulting qCDSMs and providing the relevant information to the furnishing providers during the test period “as it is important for CMS to track this information.”

Furthermore, information regarding relevant modifier codes was also included with the Change Request. Newly created modifiers ME, MF, and MG indicate to CMS that the order adhered, did not adhere, or was not applicable to the AUC, respectively. Modifier code MH is now used to indicate that it is unknown if the ordering professional consulted AUC as the information was not conveyed to the furnishing professional.

Full descriptions of each modifier code can be found at the link above.

CMS has stated that a second Change Request will follow the first at a later date. This follow up Change Request is expected to further develop and explain the new program for its 2020 use.

Full implementation of the AUC program is set for January 1, 2021 following the 2020 Education and Operations Testing Period.

For more information regarding the AUC program, please contact Adrienne Dresevic, Esq. and Clinton Mikel, Esq. at (248) 996-8510.