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Medicare Appropriate Use Criteria (AUC) Program – What You Need to Know to Properly Code [PODCAST]

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The Hospital Finance Podcast

In this episode, we are joined by Bridget Nolin, BESLER Coding Analyst, to discuss what you need to know about Medicare’s Appropriate Use Criteria program (AUC).

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Highlights of this episode include:

  • What is the AUC program
  • Advanced diagnostic imaging
  • Who will be affected by this program
  • Coding guidance specific to AUC reporting

Mike Passanante: Hi, this is Mike Passanante and welcome back to the award-winning Hospital Finance podcast. Here to discuss Medicare’s AUC, or Appropriate Use Criteria program, is Bridget Nolin, a Coding Analyst on our Revenue Integrity Services team here at BESLER. Bridget is a highly-skilled coding analyst with 20 years experience in ICD-10-CM-PCS coding, MSDRG validation, inpatient coding audits and education, and CDI reviews. She holds a Master’s in health information technology and a Bachelor’s in health information administration. Bridget is credentialed by AHIMA, as a registered health information administrator, certified coding specialist and AHIMA-approved ICD-10-CM-PCS trainer. Bridget, welcome to the show.

Bridget Nolin: Hello, Mike. It’s nice to be here.

Mike: Well, we are delighted to have you for your inaugural episode with us. So let’s hop right into it. Why don’t you start out by explaining what the AUC program is?

Bridget: Okay. Sure. Established under the 2014 Protecting Access to Medicare Act, AUC, or the Appropriate Use Criteria program’s purpose is to increase the rate of appropriate advanced diagnostic imaging services that are ordered by providers for their Medicare patients. Now, CMS will use data collected from the program to identify ordering professionals for outliers. Those providers that are identified as outliers will become subject to prior authorization. Now, I would like to take the time to inform our listeners that the AUC program was set to be fully implemented January 1st of this year, 2022. However, the implementation date has been changed to January 1st, 2023, or the January 1st that follows the end of the public health emergency for COVID-19. So until that time, the program will operate in an education and operations testing period.

Mike: Okay, got it. So Bridget, second question, when you say advanced diagnostic imaging, what would that include?

Bridget: Okay. So some examples of advanced imaging services would include computed tomography, which is a CT scan, positron emission tomography, which is a PET scan, various nuclear medicine scans, and magnetic residence imaging, which is an MRI.

Mike: And Bridget, who will be affected by this new program?

Bridget: Well, any provider who orders an advanced diagnostic imaging service and the physicians, practitioners and facilities that provide the imaging services in an applicable setting and are paid under an applicable payment system.

Mike: All right, so let’s unpack that a little bit. What are applicable settings and payment systems?

Bridget: Okay. So the applicable settings would include physician offices, hospital outpatient departments, including emergency rooms, ambulatory surgery centers, and any other provider-led outpatient setting. The words there to focus on are provider led. Any applicable payment system would include physician fee schedule, which is PFS, the hospital outpatient perspective payment system, which is OPPS, and the ambulatory surgical center, ASC, payment system.

Mike: Okay, thanks for that, Bridget. Let’s pivot a little bit and talk about the AUC specifically. So could you provide our listeners with a brief overview of how the AUC would work once it’s implemented?

Bridget: Okay. So when a provider orders one of these imaging services for a Medicare beneficiary, they will be required to consult a qualified clinical decision support mechanism, a CDSM for short. These CDSMs are electronic portals that give the provider a determination of the orders AUC adherence, or notification of no applicable AUC. There are exceptions for AUC consultations and they include if the ordering provider has a significant hardship, if the patient has an emergency medical condition or an advanced imaging service is ordered for an inpatient.

Mike: Bridget, is there a coding guidance specific to AUC reporting?

Bridget: Well, yes, there are specific coding guidance for claims processing under the AUC program. A modifier, that will be MA through MA– so that’s MA, MB, MC, MD, on and on, is reported on the same claim line as any advanced diagnostic imaging ACPCS code. You can reference appendix two of HCPCS, level two manual for description of each one of these modifiers. These modifiers indicate if a CDSM was used or not in the outcome. When a qualified CDSM was consulted, the HCPCS modifier ME, MF or MG is reported. Also, G-codes are used in conjunction with these three modifiers to indicate which CDSM was consulted. If a CDSM has been qualified by CMS but has not received an assigned HCPCS G-code, providers are to report HCPCS G1011, which is clinical decision support mechanism qualified to not otherwise specified. So to be more detailed on ME, MF and MG, ME, the order for services adheres to appropriate use criteria in the clinical decision support mechanism consulted by the ordering professional. MF, the order for this service does not adhere to the appropriate use criteria in the qualified clinical decision support mechanism consulted by the ordering professional. And MG, the order for this service does not have appropriate use criteria in the clinical decision support mechanism consulted by the ordering professional.

Mike: That’s great, Bridget, and we’ll have some more information on those modifiers on the post on our website that’s associated with this podcast so folks can read a little bit more about that. Bridget, what should providers or facilities that are not yet prepared be doing at this point?

Bridget: Okay. So if you are one of those providers or facilities, I would say, first of all, take full advantage of this additional time to participate in the education and operations testing period. During this time, claims without AUC information will not be denied. However, reporting is encouraged to allow CMS to track this information. And of course, as we all know, practice makes perfect. Also, educate yourself and your staff, including billing and/or claim staff, on the AUC program. Research which CDSM is best for you and/or your facility. Those that are referring providers, advanced imaging providers and facilities should be working to implement communication and operational processes to ensure participation is possible when the AUC program is fully implemented. Also, you can identify any of the hardship exclusion exceptions that may apply to you or your facility. And finally, discuss with ordering physicians and all your relevant staff the importance of compliance with the AUC program. I would encourage our listeners to reference the AUC, Appropriate Use Criteria program on the website for additional information, including an up to date listing of all the qualified CDSMs.

Mike: Bridget, thanks for coming by the podcast today and helping us understand more about the AUC program.

Bridget: Absolutely, Mike.


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