Knowledge Base Article

“I hope that in this year to come, you make mistakes. Because if you are making mistakes, then you are making new things, trying new things, learning, living, pushing yourself, changing yourself, changing your world. You’re doing things you’ve never done before, and more importantly, you’re doing something.”

So that’s my wish for you, and all of us, and my wish for myself. Make New Mistakes. Make glorious, amazing mistakes. Make mistakes nobody’s ever made before. Don’t freeze, don’t stop, don’t worry that it isn’t good enough, or it isn’t perfect, whatever it is: art, or love, or work or family or life.”

• Neil Gaiman, author

The Appropriate Use Criteria (AUC) Program is complex. So much so, that this is the fourth article in the last six months that MMP has dedicated to this topic and January 1st, 2020 kicked off an entire year of Education and Testing before claims for advanced diagnostic imaging services may be denied.

AUC Program Background

The Protecting Access to Medicare Act (PAMA) of 2014, Section 218(b), established a new program to increase the rate of appropriate advanced diagnostic imaging services provided to Medicare beneficiaries.

Examples of such advanced imaging services include

• Computed tomography (CT),
• Positron Emission Tomography (PET),
• Nuclear Imaging, and
• Magnetic Resonance Imaging (MRI).

Settings this program applies to include

• Physician Offices
• Hospital Outpatient Departments (including emergency department)
• Ambulatory Surgical Centers (ASCs)
• Independent Diagnostic Testing Facilities

Program Applies to services paid under the following

• Medicare Physician Fee Schedule (MPFS),
• Hospital Outpatient Prospective Payment System (OPPS), and
• The Ambulatory Surgical Center (ASC) fee schedule.

CMS Allowed Exceptions to Participation in the Program

CMS does allow exceptions to participation in the program to the following:

• Ordering professionals with a significant hardship (such as limited access to the internet, etc.),
• Patients with an emergency medical condition (note, you can read more about what is considered to be an emergency medical condition in a related MMP article), and
• Inpatient paid under Medicare Part A.

Qualified Decision Support Mechanisms

Under this program, at the time a practitioner orders an advanced diagnostic imaging service for a Medicare beneficiary, he/she, or clinical staff acting under his/her direction, will be required to consult a qualified Clinical Decision Support Mechanism (CDSM). CDSMs are electronic portals through which appropriate use criteria (AUC) is accessed. The CDSM will determine whether or not the imaging order adheres to the AUC, or if there is no AUC available to address a patient’s clinical condition. The CMS AUC Program Webpage includes a table of the current Qualified CDSMs available.  

AUC Program Purpose

Per CMS, the purpose of this program is to enable physicians, other practitioners, and facilities ordering advanced diagnostic imaging services and/or furnishing Part B advanced diagnostic imaging services to order the most appropriate test for their patient. CMS will use data collected from the program to identify outlier ordering professionals who will become subject to prior authorization.

Hospital Compare: Use of Medical Imaging Measure

AUC Program Priority Clinical Areas are defined in 42 CFR 414.94(b) as clinical conditions, diseases or symptom complexes and associated advanced diagnostic imaging services identified by CMS through annual rulemaking and in consultation with stakeholders. Priority Clinical Areas as of November 2016 includes:

• 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 diagnoses), and
• Cervical or neck pain.

Hospital Compare’s Use of Medical Imaging Measure is an outpatient imaging efficiency measure providing information about hospitals’ use of medical imaging tests (like mammograms, MRIs, and CT scans) for outpatients.  One goal of this measure is to avoid risk, stress, and cost of doing imaging tests that patients may not need.

The AUC Program Priority Clinical Area of Low Back Pain is also a Use of Medical Imaging Measure on Hospital Compare. More specifically, outpatients with low back pain who had an MRI without trying recommended treatments (like physical therapy) first.

The standard of care in patients with low back pain is to start with treatment like physical therapy or chiropractic care, and have MRI only if the treatment doesn’t help. CMS notes if the number of MRIs is high, it may mean the facility is doing too many unnecessary MRIs for low back pain. Below is a screen shot of three hospitals in the Birmingham market highlighting how they compare to each other, the state of Alabama and the Nation. Findings in this table reflect Medicare Fee-For-Service outpatient claims from July 1, 2017 through June 30, 2018.

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As evidenced in this graph, the entire state of Alabama is above the National Average, meaning facilities may be doing too many unnecessary MRIs for low-back pain.

January 1, 2020: Education and Operations Testing Period Begins

Providers are encouraged to participate during the testing period, but claims will not be denied for lack of AUC claim elements. Earlier this month CMS released MLN Article SE20002 specifically for institutional providers providing guidance for processing claims subject to the AUC program. The K3 segment will be used to report line level ordering professional information on institutional claims.

In 2020, CMS expects ordering professionals to begin consulting CDSMs and provide this information to furnishing practitioners and providers for reporting on their claims. Note, modifier MH can be utilized by furnishing practitioners and providers when they do not receive AUC-related information from the ordering professional. 

I strongly encourage key stakeholders to read this MLN article as it includes advanced diagnostic imaging UB-04 examples.

Additional Resources

While mistakes will invariably happen with such a complex process, I leave you with a few additional resources to hopefully prevent too many truly glorious, amazing mistakes.

• MMP September 24, 2019 Article: Tips on Implementing Appropriate Use Criteria http://www.mmplusinc.com/news-articles/item/tips-on-implementing-appropriate-use-criteria

• MLN Fact Sheet: Appropriate Use Criteria for Advanced Diagnostic Imaging https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/AUCDiagnosticImaging-909377.pdf

• MLN MM11268: Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging – Educations and Operations Testing Period – Claims Processing Requirements https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11268.pdf