In the calendar year 2019 Medicare Physician Fee Schedule (MPFS) Final Rule, the Centers for Medicare and Medicaid Services (CMS) finalized January 1, 2020 as the start date for the congressionally mandated appropriate use criteria (AUC)/clinical decision support (CDS) program for all advanced diagnostic imaging services. ACR staff has prepared a detailed summary of the AUC provisions of the final rule.
To meet its Jan. 1, 2020, deadline, CMS finalized its proposal to use a series of G-codes and modifiers for claims processing. The agency noted that further information on the G-codes and modifiers is forthcoming. CMS also indicated that it will consider future opportunities to use a unique consultation identifier (UCI) for claims processing and will continue to engage with stakeholders on this topic.
In response to comments in the 2018 rulemaking cycle seeking clarification on who is required to perform the consultation of AUC through a qualified clinical decision support mechanism (CDSM), CMS proposed that the consultation may be performed by “auxiliary personnel incident to the ordering physician or non-physician practitioner’s professional service.”
But in the 2019 MPFS final rule, CMS modified its proposal to state that, “when not personally performed by the ordering professional, the consultation with a qualified CDSM may be performed by clinical staff under the direction of the ordering professional.” The individual performing the AUC consultation must have sufficient clinical knowledge to interact with the CDSM and communicate with the ordering professional.
The CY 2019 final rule also addresses provisions covering the following key aspects of the program:
- To expand the definition of “applicable setting,” including the additional of independent diagnostic testing facilities (IDTFs)
- To confirm that reporting is required across claim types and by both the furnishing professional and furnishing facility
- To define and implement changes to the policy for significant hardship exceptions for ordering professionals under the program
- To identify mechanisms for claims-based reporting, and
- To request feedback on the methodology to identify outlier ordering professionals.
ACR staff and physician volunteers will continue to analyze the AUC provisions of the final rule and will submit comments to CMS by the December 31, 2018, deadline. For questions, please contact Katie Keysor at kkeysor@acr.org.