CMS to implement new appropriate use criteria for advanced diagnostic imaging in 2020

MRI machine in a hospital
Practices need to get familiar with new appropriate use criteria for advanced diagnostic imaging. (nimon/Shutterstock)

There’s a change coming for advanced diagnostic imaging services furnished in a physician’s office, hospital outpatient department or ambulatory surgery center.

Starting Jan. 1, the Centers for Medicare & Medicaid Services (CMS) will implement new appropriate use criteria (AUC) that will require ordering professionals to consult a qualified Clinical Decision Support Mechanism (CDSM) prior to ordering Medicare Part B advanced diagnostic imaging services for a patient that will take place in those settings.

Physician practices need to be aware of the change, said Robert Tennant, who provided a health IT policy update during the Medical Group Management Association (MGMA) annual conference last month.

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CMS has been testing the program with voluntary participation but will start an educational and operating testing period next year, said Tennant, director of health information technology policy for MGMA’s government affairs. Full implementation of the program will occur in January 2021.

“We’ll continue to fight this,” said Tennant about the AUC program that eventually may mean more medical professionals will be subject to prior authorization when ordering these services for patients.

The requirement that physicians get prior authorization from insurers before providing a medical service, diagnostic test or medication is already a major headache for physicians.

But initially, the AUC program will require health professionals to report a code on their claims for advanced diagnostic imaging services covered by the program including diagnostic magnetic resonance imaging, computed tomography, nuclear medicine and positron emission tomography. Starting in 2021, without a code, the claim will be rejected.

As well as checking clinical decision support tools to help make appropriate treatment decisions for the specific clinical condition, medical professionals ordering the imaging services will also need to provide the information to furnishing professionals and facilities, because they must report an AUC consultation code on their Medicare claims, according to a CMS fact sheet (PDF).

The furnishing professional and facility will need to append a new HCPCS modifier to the CPT code on the claim to denote AUC consultation occurred.

A “QQ” code will indicate that the ordering professional consulted a qualified clinical decision support mechanism for this service and the related data were provided to the furnishing professional.

For this first year, CMS will not require the AUC consultation code on advanced imaging orders or require the AUC consultation code on Medicare claims. However, starting January 2021, an AUC consultation must take place at the time of the order for imaging services that will be furnished in one of the designated settings and paid for under one of the designated payment systems that include the physician fee schedule, outpatient prospective payment system and ambulatory surgical center payment system.

But particularly worrisome for practices is that CMS will ultimately use data collected from the program to identify “outlier” ordering professionals who will become subject to prior authorization when ordering these services for patients. Advanced diagnostic imaging services covered by the AUC program include diagnostic magnetic resonance imaging, computed tomography, nuclear medicine and positron emission tomography.

Starting in 2021, CMS will collect a minimum of two years of AUC data in order to identify up to 5% of ordering professionals whose ordering patterns are considered “outliers” and subject them to prior authorization requirements. That outlier provider identification will start in 2023 at the earliest.

To help practices prepare for the changes, the MGMA has prepared a toolkit that explores how AUC can potentially alter practice workflows and action steps practices can take.

The AUC program was established by the Protecting Access to Medicare Act of 2014 legislation to reduce overutilization of services. The law included a provision seeking to increase the rate of appropriate advanced diagnostic imaging services provided to Medicare beneficiaries.

The program applies to physicians, other practitioners and facilities ordering advanced diagnostic imaging services and/or furnishing Part B advanced diagnostic imaging services to Medicare beneficiaries and billing Medicare Administrative Contractors.

Ordering professionals will be required to consult a qualified CDSM—an interactive, electronic tool for clinicians—to determine whether the order adheres to appropriateness criteria. 

CMS identified eight priority areas that it may use in determining outlier ordering professionals in the future. The initial list of priority clinical areas, defined by the agency as clinical conditions, diseases or symptom complexes, released in the CY 2017 Physician Fee Schedule Final Rule include: coronary artery disease (suspected or diagnosed), suspected pulmonary embolism, headache (traumatic and nontraumatic), hip pain, low back pain, shoulder pain (to include suspected rotator cuff injury), cancer of the lung (primary or metastatic, suspected or diagnosed), and cervical or neck pain.

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