Medicare Appropriate Use Criteria (AUC) Program

The Medicare Appropriate Use Criteria (AUC) Program is an important initiative to ensure the safe and effective use of advanced diagnostic imaging services. Staying compliant with the AUC is essential for healthcare providers to avoid penalties and maintain quality patient care.

What is the AUC?

The AUC was created by the Centers for Medicare and Medicaid Services (CMS) through the Protecting Access to Medicare Act of 2014. AUC stands for Appropriate Use Criteria, and the program ensures that Medicare B patients only receive diagnostic imaging services when medically necessary.

The program is currently pending implementation, but the AUC will be the criteria by which CMS will determine whether a diagnostic imaging service is appropriately ordered. Failure to comply could result in a claim denial, so staying up-to-date on this program is essential.

AUC Implementation

As previously stated, the AUC program was included in the Protecting Access to Medicare Act of 2014. The voluntary participation period concluded in December 2019, initiating an educational and testing phase. For this phase, Medicare claims related to the AUC were paid regardless of whether the requirements were fulfilled.

Based on the CMS’s 2022 Physician Fee Schedule final rule, the program would’ve been fully implemented on either January 1, 2023, or the following January 1, after the COVID-19 public health emergency was declared over. However, CMS recently announced on its AUC-specific website that the payment penalty phase, expected to start on January 1, 2023, would not commence as planned.

CMS announced that the educational and operations testing period will continue until further notice. CMS is unable to predict when the payment penalty period will begin.

Advanced Diagnostic Imaging

Those primarily affected by the AUC include providers ordering an advanced diagnostic imaging service, the physicians, practitioners, and facilities providing the imaging services in an applicable setting, and who are paid under a qualifying payment system. Advanced imaging services include CT scans, PET scans, nuclear medicine scans, and MRIs.

Applicable settings include the following:

• Physician offices
• Hospital outpatient departments
• Ambulatory surgery centers
• Emergency rooms
• Any other provider-led outpatient settings

Qualifying payment systems include physician fee schedules (PFS), ambulatory surgical center (ASC) payment systems, and hospital outpatient prospective payment systems (OPPS).

Coding & Modifiers Specific to the Medicare Appropriate Use Criteria Program

A provider requesting imaging services for a Medicare beneficiary must consult a qualified Clinical Decision Support Mechanism (CDSM). CDSMs are electronic portals that determine whether the orders adhere to appropriate use criteria or if there is no applicable AUC.

There is specific coding guidance for claims processing under the AUC program. Modifiers from MA through MA- MH (like MA, MB, MC, etc.) are reported on the same claim line as any advanced diagnostic imaging ACPCS HCPCS code. For a description of these modifiers, please consult Appendix II in the HCPCS level two manual.

The modifiers tell whether a CDSM was used in the outcome. When a qualified CDSM is consulted, the modifier ME, MF, or MG is reported. G-codes are also used alongside the three modifiers to show which CDSM was consulted. If CMS has approved a CDSM, but does not have an assigned HCPCS G-code, healthcare providers should use the HCPCS G1011 code to report it as a qualified CDSM.

The modifier ME refers to an ordered service that follows AUC from a consulted CDSM. The modifier MF is a requested service that does not follow AUC from a consulted CDSM. The modifier MG describes an ordered service that lacks AUC in the consulted CDSM.

Special Circumstances & Exceptions

Currently, there are four exceptions where AUC is not required, which serve as a catch-all. They include the following and must be documented using a modifier:

• If it’s a suspected or confirmed emergency condition.
• There is insufficient internet access.
• The EHR or CDSM has vendor issues.
• There are extreme and uncontrollable circumstances.

How Healthcare Providers Can Prepare

Choose a CMS-Approved CDSM

Providers have various options to comply with the Medicare Appropriate Use Criteria Program requirements outlined by CMS. By identifying which service lines and vendors they work with, they can choose an appropriate CMS-approved CDSM.

Many EHR vendors can recommend a CDSM that seamlessly integrates with their software. CMS also has a list of certified CDSMs on its website, including some free options.

Educate & Train

If you’re a provider or facility, take advantage of the this extra time for during the education and operations testing period. Even though claims without AUC information won’t be denied during this time, it’s still suggested to report the information for tracking purposes by CMS. You must also ensure all team members are adequately trained, as new HCPCS G-codes and modifiers must be reported on claims.

It’s necessary to inform all referring and rendering providers about the changes and train them on CMS requirements. Ensure that the newly implemented processes comply with regulations. Referring providers, advanced imaging providers, and facilities must establish communication and operational processes to enable participation once the AUC program is fully implemented.

Prepare for the “Go-Live”

Although the testing phase has taken a long time and the program implementation has been postponed again, it’s crucial to comprehend the program, fulfill the requirements, and prepare for going live. After the AUC program is implemented, noncompliance with CMS’s standards and the AUC outcome may result in a provider’s claims being denied.

If a provider’s ordering patterns are considered outliers by CMS, they may have to get prior authorization even if their claims are denied. If the provider does not consult a CDSM or report the correct code and modifier repeatedly, their diagnostic imaging may have to be pre-approved, which is unfortunate.

Learn More About the Medicare Appropriate Use Criteria Program with BESLER

The Medicare Appropriate Use Criteria Program is a complex system of coding and modifiers for imaging services that healthcare providers must follow when processing claims. By understanding the basic requirements, selecting a CMS-approved CDSM, using the proper coding and modifiers, educating staff, and preparing for “go live,” providers can be sure they remain compliant with the program’s standards.

For more information, listen to two of BESLER’s The Hospital Finance Podcast™ episodes and watch our Medicare Appropriate Use Criteria Program webinar using the links below. With our valuable resources, healthcare providers can ensure compliance.