RBMA: What You Need to Know About Looming Appropriate Use Criteria Implementation


Coding and reimbursement expert Melody Mulaik offers insights about what the industry should do to fully prepare for the likely mandatory implementation of appropriate use criteria and clinical decision support.

Radiology has been anticipating the full implementation of Appropriate Use Criteria (AUC) and clinical decision support (CDS) since 2014 with the Protecting Access to Medicare Act, and it finally appears the industry could finally be seeing light at the end of the tunnel. So, it is now more critical than ever to be familiar with the next steps and implementation process.

In an Aug. 3 session during the Radiology Business Management Association (RBMA) PaRADigm Shift 2020 virtual conference, industry coding and reimbursement expert Melody Mulaik, MSHS, FAHRA CRA, RCC, CPC, CPC-H president of Revenue Cycle Coding Strategies, LLC, outlined how radiologists can prepare for full AUC and CDS implementation and what remaining challenges could be out there.

“At this point, we really should be pretty far along in the implementation process, and hopefully, you are working through some of the finer points and the implementation of the details related to this process,” she said. “But, I want to remind you as you’re working with people who are implementing these things, they don’t have the level of understanding around the guidelines that you do. While we’ve been talking about this in the imaging world for many years, for a lot of organizations, this is the first year they’re talking about this now that the deadline is looming.”

Compliance is important, she added, because the Centers for Medicare & Medicaid Services (CMS) will refer to AUC and CDS use to identify the top 5 percent of providers who most frequently order inappropriate imaging. CMS will, then, require prior authorization for any advanced imaging services ordered by those outlier providers.

Where We Are with Implementation

After several years of delays, the Centers for Medicare & Medicare Services (CMS) determined 2020 would be a testing year, confirming they would process payment whether an AUC consultation supported imaging. Currently, the industry is planning for full implementation on Jan. 1, 2021, with the expectation that payments will be denied if AUC protocols are not followed properly.

But, that start date is not set in stone, Mulaik said. CMS has not yet released its Proposed Rule, meaning the Final Rule is not likely until December of this year. The hope, she explained, is that mandatory implementation will be delayed for at least another six months to one year to allow all clinical environments to fully comply.

And, those compliance requirements remain the same. Referring providers must consult AUC when ordering imaging for outpatients and individuals in observation, and they must relay the consultation results to the radiologist directly. Radiologists must also comply with the regulations. Exemptions can be made for inpatient scans, emergency studies that fall under EMTALA, critical access hospitals, and providers who have a hardship, such as an internet outage. Published CMS guidance offers more specific details for a variety of situations.

Once it is fully implemented, AUC will initially focus on at least eight priority clinical areas – coronary artery disease, suspected pulmonary embolism, headache, hip pain, low back pain, cervical or neck pain, shoulder pain, and lung cancer. Remember, though, that AUC applies to all advanced imaging – not just these eight areas.

What Should You Do?

Remember that CDS use is required for claims submitted with Medicare as the primary insurance. But, do not forget claims where Medicare is listed as the secondary payer, as well. Mulaik recommended beginning to test claims with commercial payers now to work through any obstacles or glitches before the implementation deadline.

To be in full compliance on Jan. 1, 2021, Mulaik advised submitting claims to CMS that include one G-1011 code per mechanism and attaching modifiers at the CPT code level to indicate AUC adherence. Referring providers or their direct clinical staff must report the codes – if facility staff do it, it is a compliance violation, she said.

There are currently eight modifiers:

  • -MA: CDS consult not required because the patient has suspected or confirmed emergency medical condition
  • -MB: CDS consult not required due to insufficient internet access hardship exception
  • -MC: CDS consult not required due to electronic health record or CDS mechanism vendor issue hardship exception
  • -MD: CDS consult not required due to extreme and uncontrollable circumstances hardship exception
  • -ME: Ordered service adheres to AUC
  • -MF: Ordered service does not adhere to AUC
  • -MG: Ordered service does not have AUC in the CDS mechanism
  • -MH: Unknown if referring provider consulted CDS for ordered service

Although it has not been announced, it is possible the -MH modifier will disappear once full implementation is enacted, Mulaik advised. If you submit a claim with it after Jan. 1, 2021, it is likely your claim will be denied because CMS will no longer accept that you do not know whether your referring providers are using CDS.

CMS has also not yet provided clarity about what modifier radiologists should use if the technical component of a service was performed in a non-applicable setting, such as a critical access hospital. It is possible CMS could provide another modifier to indicate this situation, she added.

Existing Challenges and Metrics

As a radiologist, the long-standing challenge with AUC has been the lack of control you have over whether referring providers correctly complete the process. With AUC being intergrated into the electronic health record, this will become less of a concern with hospital-based referring providers. Still, Mulaik said, ensuring compliance with community-based, non-hospital employed physicians could be an ongoing obstacle. When possible, identify who the gatekeeper is in those practices to ensure the AUC compliance process is observed and completed correctly.

In addition, possible code denials and slow adoption from providers can also be stumbling blocks. Begin testing now before implementation is mandatory so you can flush out any potential problems and figure out workable solutions.

But, there are ways you can keep tabs on AUC performance, she said. Reviewing this information can let you know where additional work is needed. She suggested these metrics as good indicators for AUC compliance:

  • Examining utilization by provider and practice both pre- and post-implementation.
  • Analyzing CDS mechanism scores by providers.
  • Evaluating primary and secondary payer denials, distinguishing between AUC and medical necessity rejections.
  • Identifying any missing AUC information by provider and facility staff to determine where omissions occur most frequently.
  • Segment out AUC compliance by modality when appropriate.

Ultimately, Mulaik said, it is critical that you continue to impress upon your referring providers that they should be developing the AUC and CDS habit now. Even as more guidance from CMS is forthcoming and the proposed and final rules are yet to be published, working through any pain points now with coding errors and denials could pave the way for smoother reimbursement for services rendered once full implementation is in place.

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