Appropriate Use Criteria:
Claims and Billing Guidance Arrives
CMS is committed to advancing AUC, motivating radiologists to implement the program.
On July 26, CMS released two documents updating the Appropriate Use Criteria (AUC) program, mandated by PAMA.1,2 The document restates the implementation timeline from previous CMS communications, including last year’s Medicare Physician Fee Schedule Final Rule. The anticipated guidance on billing claims is provided below. The education and operations testing period begins on Jan. 1, 2020, with full implementation of the AUC program expected Jan. 1, 2021.
During the education and operations testing period, CMS expects ordering professionals to begin consulting CDS mechanisms (CDSMs) and provide claims reporting information to the furnishing professional. CMS indicates that “claims will not be denied for failing to include AUC-related information or for misreporting AUC information.” In other words, payment is not at risk during 2020 — even if no information is provided. However, CMS goes on to state that “even though claims will not be denied … inclusion is encouraged as it is important for CMS to track the information.”
CMS has created eight new modifiers to indicate the outcome of the AUC consultation (see Table 1).
1. When an AUC is consulted (ME through MG)
2. When a CDSM is not consulted — for instance due to hardship (MA through MD, MH)
CMS has also created 12 G-codes, which are Healthcare Common Procedure Coding System codes for reporting purposes. Each G-code is specific to one of the CMS-approved CDSMs. There is also a G-code for “not otherwise specified.” For instance, the G-code for the National Decision Support Company is G1004.
These modifiers should be placed on the same line on the claim form as the CPT® code for the advanced diagnostic imaging service, including MR, CT, and PET. Claims that report ME, MF, or MG — which indicate CDSM consultation — must also include the G-code for the qualified CDSM.
For those interested in claims processing, CMS provided further information regarding the G-codes (see Table 2). These new AUC-related G-codes are different than other G-codes as they do not include payment amounts (i.e., they are only for reporting). Each Medicare Administrative Contractor shall adjudicate these no-pay G-code line items with the messages in Table 3. CMS indicates that subsequent change requests will follow at a later date, which will further operationalize the AUC program.
The transmittals confirm CMS’ commitment to advancing this program — motivating radiology professionals to explore and implement the program. Payments are not at risk in 2020, providing time for education and testing before full implementation in just over a year.
By Ezequiel Silva III, MD, FACR, Chair
1. CMS Manual System: Pub 100-20 one-time notification, transmittal 2323, change request 11268. Accessed July 26, 2019.
2. CMS. MLN Matters Number: MM11268. Accessed July 27, 2019.