Specific modifiers and G-Codes for claims processing under the Acceptable Use Criteria (AUC)/Clinical Decision Support (CDS) program have been released as of July 26th. As the Education & Operational Testing period for the program begins January 1st, 2020, it is important that practices are taking steps to prepare for the program’s full implementation in 2021 in order to avoid negative impacts on reimbursement. Advocate is committed to supporting our clients through this process by providing resources and communication as more information pertaining to the AUC/CDS program is released.

What are the AUC/CDS modifiers and G-codes?

AUC Codes (HCPCS Modifiers)

Modifier Purpose Does it need a G-Code?
MA Ordering professional is not required to consult a clinical decision support mechanism due to service being rendered to a patient with a suspected or confirmed emergency medical condition NO
MB Ordering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of insufficient internet access NO
MC Ordering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of electronic health record or clinical decision support mechanism vendor issues NO
MD Ordering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of extreme and uncontrollable circumstances NO
ME The order for this service adheres to the appropriate use criteria in the clinical decision support mechanism consulted by the ordering professional YES
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 YES
MG The order for this service does not have appropriate use criteria in the clinical decision support mechanism consulted by the ordering professional YES
MH Unknown if ordering professional consulted a clinical decision support mechanism for this service, related information was not provided to the furnishing professional or provider NO
QQ Ordering professional consulted a qualified clinical decision support mechanism N/A

G-Codes – These indicate which CDSM was consulted, these are to be used in conjunction with HCPCS codes ME, MF, and MG.

G-Code CDSM
G1000 Clinical Decision Support Mechanism Applied Pathways, as defined by the Medicare Appropriate Use Criteria Program
G1001 Clinical Decision Support Mechanism eviCore, as defined by the Medicare Appropriate Use Criteria Program
G1002 Clinical Decision Support Mechanism MedCurrent, as defined by the Medicare Appropriate Use Criteria Program
G1003 Clinical Decision Support Mechanism Medicalis, as defined by the Medicare Appropriate Use Criteria Program
G1004 Clinical Decision Support Mechanism National Decision Support Company, as defined by the Medicare Appropriate Use Criteria Program
G1005 Clinical Decision Support Mechanism National Imaging Associates, as defined by the Medicare Appropriate Use Criteria Program
G1006 Clinical Decision Support Mechanism Test Appropriate, as defined by the Medicare Appropriate Use Criteria Program
G1007 Clinical Decision Support Mechanism AIM Specialty Health, as defined by the Medicare Appropriate Use Criteria Program
G1008 Clinical Decision Support Mechanism Cranberry Peak, as defined by the Medicare Appropriate Use Criteria Program
G1009 Clinical Decision Support Mechanism Sage Health Management Solutions, as defined by the Medicare Appropriate Use Criteria Program
G1010 Clinical Decision Support Mechanism Stanson, as defined by the Medicare Appropriate Use Criteria Program
G1011 Clinical Decision Support Mechanism, qualified tool not otherwise specified, as defined by the Medicare Appropriate Use Criteria Program

Background on AUC/CDS

  • PAMA (Protecting Access to Medicare Act) established the Acceptable Use Criteria for Advanced Diagnostic Imaging requirements which states that (beginning 1/1/2020) ordering physicians must consult AUC through the use of a qualified CDSM (Clinical Decision Support Mechanism) prior to ordering advanced diagnostic imaging services (CT, MRI, PET and nuclear medicine)
  • January 1st 2020 – the Educational & Operations testing period for the program begins, claims must contain information pertaining to participation in AUC/CDS program but there is no impact to the claim being paid if not present
  • January 1st 2021 – claims must contain information pertaining to participation in AUC/CDS program and claims will not be paid if not present

What AUC/CDS information needs to be on a claim?

  • The name of the ordering physician and their NPI number
  • Modifiers related to Acceptable Use Criteria
    • These modifiers encompass either that a CDSM was consulted and what the outcome was (AUC was met, not met or not available) OR that a CDSM could not be consulted for some reason
  • G-Code identifying which specific CDSM was used, when applicable. Each CDSM has a unique G-code.

Who is required to consult the CDSM to obtain the required approval?

  • The rule requires ordering physicians or his/her auxiliary personnel to consult an approved CDSM to obtain AUC.
  • CMS defines auxiliary personnel as clinical staff under the direction of the ordering professional. Accordingly, the ordering doctor can exercise their discretion in delegating the actual performance of the CDSM consultation with the understanding that the staff member must have sufficient clinical knowledge and the ability to interact with the qualified CDSM.

 What are the care settings where AUC consolations are required?

AUC requirements apply to advanced imaging services furnished in the following settings;

  • Ambulatory surgical centers
  • Hospital outpatient settings (including emergency department, however exceptions are allowed for cases where there is a true emergency – indicated by the MA modifier)
  • Independent diagnostic testing facilities (IDTF)

This requirement includes claim submissions for the professional, technical and global service

What to do to get ready?

Advocate understands the significant impact this program will have as well as the concerns our clients are facing as AUC/CDS rolls out.  We suggest being as proactive as possible and keeping the following in mind:

  • Get familiar with the AUC/CDS program – See resource section for more details
  • Start working with your facilities and referring physicians now – Click here for our suggestions on beginning the AUC/CDS conversation
  • Advocate is here to help – Reach out to us for support and Advocate will keep you up to date with information as it becomes available.

 Resources

Advocate Resources