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Update to Appropriate Use Criteria (AUC) Mandate

The AUC Mandate has been pushed back to January 1, 2020. On that date, the Protecting Access to Medicare Act (PAMA) will require referring providers to consult appropriate use criteria (AUC) prior to ordering advanced diagnostic imaging services – CT, MRI, PET, and nuclear medicine exams – for Medicare patients.

As we move towards mandatory implementation of this rule, questions remain with regards to how an ordering physician will prove they consulted a qualified clinical decision support (CDS) mechanism prior to ordering advanced imaging, how will that proof be passed along to the imaging practice, and how will the CDS consultation be indicated on the Medicare claim form that will be submitted by the imaging center?

Earlier this month, the Centers for Medicare and Medicaid Services (CMS) finally published some answers. Starting July 1, 2018, providers can use a new Healthcare Common Procedure Coding System (HCPCS) modifier (QQ) to indicate that CDS was consulted. Reporting is voluntary at this point, but we can anticipate that it will become mandatory once the CDS requirement is closer to being fully implemented in 2020.

Ordering physicians should begin to implement CDS consultation with their advanced imaging exams in anticipation of the mandatory requirement. This would be a good opportunity to begin testing the process of communicating about CDS and ensuring that all imaging orders that went through a CDS consultation reliably include the QQ modifier applied to the coding and billing stage.

Providers who have questions about how to use the QQ modifier should first review the MLN Matters (issue MM10481) that CMS posted on March 2, 2018. It covers the history of the CDS requirement, where to find a list of qualified CDS mechanisms, who will be subject to the CDS consultation requirement, the most common code families the requirement would apply to, exceptions to the rule, and more. The MLN Matters document also has a reminder about the additional things CMS will want reported once the requirement is scheduled to become mandatory on January 1, 2020. This includes the ordering practitioner’s National Provider Identification (NPI) and documenting which qualified CDS mechanism the ordering professional consulted. Guidance on how to report this on a claims form is not ready yet, but will need to be published before CDS becomes mandatory.

We will post updates as we receive them.

For additional information online:

Qualified Clinical Decision Support Mechanisms (CDSMs)

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