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Medicare Appropriate Use Criteria Program-What You Need to Know to Properly Code Webinar [PODCAST]

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The Hospital Finance Podcast

In this episode, we’re pleased to welcome back Kristen Eglintine, Coding Analyst Supervisor at BESLER, to give you a glimpse into the upcoming BESLER webinar Medicare Appropriate Use Criteria, or AUC, Program: What You Need to Know to Properly Code.

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Highlights of this episode include:

  • AUC program
  • When this program will go live
  • Diagnostic imaging
  • Exceptions to CMS’s requirements
  • How providers can prepare

Kelly Wisness: Hi, this is Kelly Wisness. Welcome back to the award-winning Hospital Finance Podcast. We’re pleased to welcome back Kristen Eglintine, coding analyst supervisor here at BESLER. In this episode, we’re going to give you a glimpse into the upcoming BESLER webinar Medicare Appropriate Use Criteria, or AUC, Program: What You Need to Know to Properly Code. Kristen and a colleague are hosting it on Wednesday, January 25, at 1:00 PM Eastern Time. Thank you for joining us today, Kristen.

Kristen Eglintine: Well, hello, Kelly. Thank you for having me. Hello, listeners. It’s a new year, so happy new year to all.

Kelly: Great. Well, let’s go ahead and jump in today. So, as I mentioned, we will be discussing the AUC program in this episode. Can you take a minute and explain this program to us?

Kristen: Absolutely. So, AUC stands for the appropriate use criteria. Centers for Medicare and Medicaid Services, otherwise known as CMS, created the AUC program through the Protecting Access to Medicare Act of 2014. And they did this to help ensure that diagnostic imaging services would only be provided where medically necessary, and this is for Medicare B patients. The program is currently pending implementation, but the AUC will be the criteria by which CMS will determine whether a diagnostic imaging service has been appropriately ordered. Failure to comply could result in claim denial, so it’s important that we are all up to speed on this program.

Kelly: Thank you for that. And you mentioned that the program is pending implementation. When will this program go live?

Kristen: Great question. The AUC program was part of the Protecting Access to Medicare Act of 2014, like I just mentioned. The voluntary participation period ended December of 2019 with the start of an educational and testing period. And during this period, Medicare claims associated with the AUC were paid regardless, whether AUC requirements were met or not. And then per CMS’s 2022 Physician Fee Schedule final rule, they said the program was set to be fully implemented on the later of January 1 of 2023 or the January 1 that follows the declared end of our public health emergency for COVID-19. Most recently, CMS had posted on their AUC-specific website that the payment penalty phase will not begin on January 1 of 2023, which we were all expecting. Even if the public health emergency for COVID ended in 2022, they were not going to start the penalty phase. [And?] they also stated that until further notice, the educational and operations testing period is going to continue and that CMS is unable to forecast when the payment penalty phase will begin. So, to answer your question, we aren’t sure when it’s going live. We’re remaining in an educational and operations testing period for the foreseeable future.

Kelly: [laughter] Very interesting. So, if CMS’s goal is to ensure diagnostic imaging is ordered only when medically necessary, how will CMS determine that?

Kristen: CMS will require the ordering provider to consult a qualified clinical decision support mechanism. That’s a lot of words…so we’re calling it a CDSM for short. CDSM, it’s an interactive electronic tool for clinicians that give the users AUC information that can be used to make the most patient-appropriate treatment decisions for their special condition that they have. So if a provider orders a diagnostic MRI for a patient with Medicare part B coverage, AUC must be consulted through a CDSM. Specific codes and modifiers will be reported to alert CMS that the ordering physician did this properly.

Kelly: Okay, I think that makes sense. And what type of diagnostic imaging service will require AUC?

Kristen: Advanced diagnostic imaging services that will require the AUC are MRIs, like I just mentioned, or CAT scans. PET scans will also require it, as well as nuclear medicine testing. The AUC requirement is for outpatient imaging services, so in other words, patients covered by Medicare part B. Medicare part B covers two types of services: medically necessary services such as doctors, services, and tests, outpatient care, home health services. It also covers your durable medical equipment and other medical services, in addition to some preventative services are covered under Medicare part B. So therefore, the AUC program applies to settings such as physician offices, hospital outpatient departments – and that does include emergency departments – ambulatory surgical centers, or independent diagnostic testing facilities.

Kelly: Okay, thank you for that explanation. And are there any exceptions to CMS’s requirement?

Kristen: Yes, we have four exceptions as of now. So, under these four exceptions, AUC is not required. And those exceptions are whether it’s a suspected or confirmed emergency condition, if there is insufficient internet access, if your EHR or your CDSM has vendor issues, or extreme and uncontrollable circumstances. That’s kind of like your catch-all bucket. However, all of these situations, these four examples, they are required to be documented through the use of a modifier. So, I’ve mentioned the use of modifiers a few times now, so let me just expand on that just for a moment. So right now, there are nine modifiers. There’s a modifier ME, and this should be appended to a claim when an order adheres to the AUC in a qualified CDSM. Then we have four different modifiers used for the exceptions that I just mentioned above. And there’s a few more modifiers, and they are to be used when the ordering service does not adhere to the AUC.

Kelly: Okay, sounds good. And is there anything a provider can do to prepare for the impending implementation of this program?

Kristen: There are multiple things a provider can do. So, you could check the AUC program requirements, and they are outlined by CMS. You can then identify which service lines and vendors that you work with may be affected. You would choose an appropriate CMS-approved CDSM. Most of your EHR vendors, they could recommend one that fits seamlessly with their software. CMS also has provided a list of certified CDSMs on their website, and they’ve included some free options as well there. You could communicate changes to staff. It’s important that all referring and rendering providers are aware and that they are trained on the requirements by CMS. We want to encourage dialogue and clarify new ways of working together. You could consider the impact that this will have on your management teams and, again, ensure that all staff is trained on the new requirements since there are new HCPCS G-codes and modifiers that now must be reported on the claims.

Additionally, you will make sure any additional staff knows how to process claims and the potential networking that may be required after this program is implemented. And then wrap it all up and make sure that all of the new processes that you put into place are compliant. And while it seems we’ve been in this testing phase for years and then, once again, this implementation has been delayed, it is important to understand the program and to know the requirements and be ready to go live because once the AUC program is fully implemented, the consequence for failing to comply with CMS’s requirements, and then also based on the outcome of the AUC, a provider does risk their claims being denied. And in addition to their claims being denied, a provider who’s ordering patterns are considered outliers by CMS will be subject to prior authorization. So, meaning that if a provider repeatedly does not either consult a CDSM or it doesn’t report the correct code and modifier, they may have all of their diagnostic imaging have to be pre-approved, which would be unfortunate.

I would just like to also say that I will be hosting a webinar on Wednesday, January 25 at 1:00 PM Eastern Time on the AUC program going through everything I just talked about in more detail. I, along with another BESLER analyst, Sara Clark, will be diving deeper into the proper coding for Medicare’s AUC program. We’re also going to look at special circumstances and explore some frequently asked questions about the impending AUC program.

Kelly: Sounds great. Yeah, it sounds like something that listeners won’t want to miss.

Kristen: I agree. The program– like I had said, was first created back in 2014, so it’s been around for a while. It was in this voluntary participation phase. Then it went to the educational and testing phase, which we are currently in. So, it’s been around, but until something is truly implemented, you may not fully understand the impact it will have on your facility. So, it is good to always stay on top of the subject matters to make sure things aren’t changing and just be ready so when CMS says we’re going, you don’t miss a beat.

Kelly: Sure. No, we appreciate that. And we appreciate you joining us today, Kristen, and for sharing some of this great information that you’re going to be sharing in that upcoming webinar on January 25.

Kristen: Thank you, Kelly, and thank you, listeners, for joining us today. And I look forward to talking to you again.

Kelly: Sounds great. Me too. And thank you all for joining us for this episode of The Hospital Finance Podcast. Until next time…

[music] This concludes today’s episode of the Hospital Finance Podcast. For show notes and additional resources to help you protect and enhance revenue at your hospital, visit The Hospital Finance Podcast is a production of BESLER, SMART ABOUT REVENUE, TENACIOUS ABOUT RESULTS.


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