January 1, 2020, marks the start of the Appropriate Use Criteria (AUC) program educational and operations testing period, at which time Medicare Administrative Contractors (MACs) will begin accepting AUC-related modifiers on claims for advanced diagnostic imaging services furnished to Medicare Part B patients. The voluntary participation period ends December 31, 2019.

Know AUC Program Requirements

In 2020, the Centers for Medicare & Medicaid Services (CMS) expects ordering professionals to begin consulting qualified Clinical Decision Support Mechanisms (CDSMs) prior to ordering advanced imaging services in applicable settings for Medicare patients and providing information to the furnishing professionals for reporting on their Medicare Part B claims.

Advanced imaging includes:

• Magnetic resonance image
• Computed tomography
• Single-photon emission computed tomography (CPT 76390)
• Nuclear medicine

For a complete list of applicable codes, see Attachment 1 in CMS Transmittal 2323, Change Request 11268, issued July 26, 2019.

Who Must Comply with AUC Program Requirements?

The applicable settings (where the imaging service is furnished) include:

• Physician offices
• Hospital outpatient departments (including emergency departments)
• Ambulatory surgical centers (ASCs)
• Independent diagnostic testing facilities

The applicable payment systems include:

• Physician Fee Schedule
• Outpatient Prospective Payment System
• ASC PS

Exceptions to the CDSM requirement include:

• The ordering professional has a significant hardship
• The patient has an emergency medical condition
• The patient is an inpatient and the service will be billed under Part A

What Are the Reporting Requirements?

The following HCPCS Level II modifiers have been established for the AUC program.

• 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 (effective date: July 1, 2018)

To indicate the appropriate CDSM requirement has been met, you will place the corresponding modifier on the same claim line as the CPT or HCPCS Level II C code for the advanced diagnostic imaging service.

These HCPCS Level II modifiers describe either the level of adherence or an exception to the program. For claims that report modifier ME, MF, or MG, you will also need to include the corresponding HCPCS Level II G code(s) on a separate claim line to identify the qualified CDSM consulted (qualified CDMS are in red):

• 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

These G codes are for reporting purposes only. If a nominal charge amount is required for operational reasons related to claims processing, the Medicare patient is not responsible for the denied charges.

This Is Just a Test, for Now

During this phase of the program, MACs will not deny claims for failing to include AUC-related information or for misreporting AUC information on non-imaging claims. Full AUC program implementation is expected Jan. 1, 2021.

Source: CMS MLN Matters article MM11268. July 26, 2019