Doctors
Supporting The
Physicians We Serve.
Appropriate Use Criteria
From the Center of Medicare and Medicaid
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 medicine (NM)
magnetic resonance imaging (MRI)
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 provides a determination of whether the order adheres to AUC, or if the AUC consulted was not applicable (e.g., no AUC is available to address the patient’s clinical condition). A consultation must take place at the time of the order for imaging services that will be furnished in one of the below settings and paid for under one of the below payment systems. Ultimately, practitioners whose ordering patterns are considered outliers will be subject to prior authorization. Information on outlier methodology and prior authorization is not yet available.
This program impacts all physicians and practitioners (as defined in 1861(r) or described in 1842(b)(18)(C)), that order advanced diagnostic imaging services and physicians, practitioners and facilities that furnish advanced diagnostic imaging services in a physician’s office, hospital outpatient department (including the emergency department), an ambulatory surgical center or an independent diagnostic testing facility (IDTF) and whose claims are paid under the physician fee schedule, hospital outpatient prospective payment system or ambulatory surgical center payment system.
Program Timeline
Currently, the program is set to be fully implemented on January 1, 2021 which means AUC consultations with qualified CDSMs are required to occur along with reporting of consultation information on the furnishing professional and furnishing facility claim for the advanced diagnostic imaging service. Claims that fail to append this information will not be paid. Prior to this date the program will operate in an Education and Operations Testing Period starting January 1, 2020 during which claims will not be denied for failing to include proper AUC consultation information. Beginning July 1, 2018 the program is operating under a voluntary participation period during which time consultations with AUC may occur and may be reported on furnishing professional and facility claims using HCPCS modifier QQ.
Rules and Regulations
These policies are codified in our regulations at 42 CFR 414.94.
The CY 2016 Physician Fee Schedule (PFS) Final Rule with Comment Period introduced this program (pages 71102-71116 and pages 71380-71382).
Additional policies related to this program are included in the CY 2017 PFS Final Rule (pages 80403-80428 and pages 80554-80555).
The CY 2018 PFS Final Rule includes requirements for consulting and reporting under the Medicare AUC program (pages 53187-53201 and page 53363).
Further updates to the AUC program are included in the CY 2019 PFS Final Rule (pages 59688-59701 and page 60074).
Questions regarding this program may be submitted to the CMS Imaging AUC resource box: [email protected].
Clinical Decision Support Mechanisms
Qualified Clinical Decision Support Mechanisms as of June 2019
AgileMD’s Clinical Decision Support Mechanism
AIM Specialty Health ProviderPortal®*
Applied Pathways CURION™ Platform
Cranberry Peak ezCDS
eviCore healthcare’s Clinical Decision Support Mechanism
EvidenceCare’s Imaging Advisor
Inveni-QA’s Semantic Answers in Medicine™
MedCurrent OrderWiseTM
Medicalis Clinical Decision Support Mechanism
National Decision Support Company CareSelect™*
National Imaging Associates RadMD
Reliant Medical Group CDSM
Sage Health Management Solutions Inc. RadWise®
Stanson Health’s Stanson CDS
Test Appropriate CDSM*
Clinical Decision Support Mechanisms with Preliminary Qualification as of June 2019
Cerner CDS mechanism
Evinance Decision Support
Flying Aces Speed of Care Decision Support
HealthHelp’s Clinical Decision Support Mechanism
Infinx CDSM
LogicNets’ Decision Engines
New Century Health’s CarePro
*Indicates free version available
Appropriate Use Criteria 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 |
| Ordering professional consulted a qualified clinical decision support mechanism | N/A |
HCPCS Codes
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 |