Outpatient Facility Coding Alert

See what it takes to streamline the process between ordering and furnishing providers.

The year 2020 will introduce sweeping changes to the way that providers order advanced diagnostic imaging services (ADIS) for Medicare Part B patients. The Centers for Medicare and Medicaid Services (CMS) will incorporate these changes by way of the Protecting Access to Medicare Act (PAMA), established in 2014.

There are plenty of fine details that providers on both ends of the diagnostic order are going to want to concern themselves with, but the chain of command doesn’t stop with physicians. Coders and practice managers are also going to want to get on board with the various components of what these changes entail. Specifically, you’ll want to get to know two underlying components of the act — appropriate use criteria (AUC) and qualified clinical decision support mechanism (qCDSM). Without a firm grasp of these concepts, and more, you’re putting both the ordering and furnishing provider at risk of payment denials.

Find your footing and hit the ground running in 2020 by considering how your role will be affected by the new rules for ADIS reporting.  

See What PAMA Fully Entails

To begin, you’ll want to get comfortable with what exactly Medicare is requiring with this new policy. With PAMA, CMS wants to ensure that ordering providers are taking all appropriate measures before ordering an ADIS for their patients. CMS explains that this new program was established “to increase the rate of appropriate advanced diagnostic imaging services rendered to Medicare beneficiaries.” More specifically, an ADIS includes any of the following diagnostic imaging services:

• Computed tomography (CT or CTA)
• Magnetic resonance (MRI or MRA)
• Nuclear medicine
• Positron emission tomography (PET).

Before an ordering provider may order an ADIS, the physician must consult a set of preliminary criteria known as AUC. AUC is a set of criteria established by CMS that a physician should follow when determining whether an order for ADIS is appropriate.

The process of meeting AUC involves the ordering physician consulting a qCDSM. This means that the provider will access an electronic portal and enter information regarding the patient’s respective clinical indications. According to CMS, “the CDSM will provide the ordering professional with a determination of whether that order adheres to appropriate use criteria, does not adhere to appropriate use criteria, or if there is no appropriate use criteria applicable.”

Background: The AUC for diagnostic radiology is based on the American College of Radiology (ACR) Appropriateness Criteria (AC). Generally speaking, the AUC calculates the cost-benefit ratio with respect to the patient’s condition and the imaging ordered. For instance, AUC will indicate that computed tomography (CT) scan with and without contrast is “Usually not appropriate” for a patient with right upper quadrant pain. Using a qCDSM prior to ordering imaging essentially forces the ordering provider to access the ACR’s AC page to determine whether the patient’s condition is, in fact, medically necessary based upon their criteria.

Consider Impact on Ordering, Furnishing Physician Practices

Now that you understand the basic nuances of what’s needed to reach AUC, you might be wondering how you, as a coder, biller, or practice manager, are affected by this new policy. If you work in a diagnostic radiology setting, you’ll be the one required to translate the AUC and qCDSM process into an HCPCS code and respective modifier. CMS requires that any ADIS furnished by a radiologist be submitted with the appropriate HCPCS code and HCPCS modifier in addition to the underlying ADIS CPT^® code.

Until 2020, CMS has implemented a voluntary reporting period. Beginning in 2020 (Educational and Operations Testing Period where reimbursement will not be affected), once documentation is received that the ordering provider consulted a qCDSM, the coder will append modifier QQ (Ordering Professional Consulted A Qualified Clinical Decision Support Mechanism For This Service And The Related Data Was Provided To The Furnishing Professional) to a respective HCPCS G code. These G codes will presumably be introduced in the 2020 edition of the HCPCS manual.

Coder’s note: Keep in mind that you will have a selection of G codes to choose from depending on the results of the qCDSM. Using a respective G code, coders will report “which qCDSM was consulted, the results of the consultation (adhere, not adhere or not applicable) and the tax identification number (TIN) of the referring physician,” according to CMS.

Begin Educating Providers Sooner Than Later

If you already struggle to receive orders with appropriate clinical indications from your ordering providers, this new set of hurdles to jump through may be understandably frustrating.

“There has been more accountability and monitoring with new AUC implementation measures in the works,” says Kimberly M. Fifer, CPC, CEDC, manager of coding operations at Revenue Cycle Management in Roanoke, Virginia. “Ordering physicians are hoping that, somehow, when they place an order for a procedure, the system can ‘give’ them a list of appropriate codes — but it’s not that simple,” Fifer explains.

With this new policy, coders, billers, and practice managers alike will need to work as a unit in order to make sure that documentation is received and processed from the ordering physician. Radiology practices must receive documentation each time an ordering provider consults with a qCDSM. Once documentation is received, implement a streamlined system so that the coders can easily access this documentation and report the respective HCPCS codes and modifiers to CMS.

Fortunately, Medicare is giving you the chance to refine your strategies while working with referring physicians’ offices by running an “education and operations testing period” from January 1, 2020 through December 31, 2020. During this time, there will be no penalties for incorrect reporting.

You can access more information surrounding ACU for ADIS here:  https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/AUCDiagnosticImaging-909377.pdf.

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