Radiology Coding Alert

Stay ahead of the curve and ensure no payments get left behind.

You might have heard the news about the Protecting Access to Medicare Act (PAMA) requirements involving the consultation of appropriate use criteria (AUC) for referring providers prior to ordering advanced diagnostic imaging (ADI) services. The rules enforced in PAMA fundamentally change the way a physician orders ADI services.

However, it also fundamentally impacts how the coders for the furnishing radiologist report the services. Ensuring payment for the professional component (PC) and technical component (TC) means a collaborative effort between the ordering and furnishing provider practices,” says Barry Rosenberg, MD, chief of radiology at United Memorial Medical Center in Batavia, New York. “There will certainly be some bumps along the way, but a proper channel of communication will pave the way to success,” Rosenberg adds.  

Check out the following frequently asked questions (FAQs) to stay on top of all the pertinent details regarding PAMA and how it concerns you.

FAQ: How does this affect my radiology practice?

The introduction of PAMA rules and regulations regarding AUCS and qCDSMs impacts the practice of both the ordering and furnishing provider — albeit in different ways. The ordering provider must not consult AUC using a qCDSM prior to making a referral for any one of the following ADI services:

• Computed tomography (CT),
• Magnetic resonance imaging (MRI),
• Nuclear medicine, and
• Positron emission tomography (PET).

Furthermore, the ordering physician must relay to the furnishing physician practice that they consulted AUC using a qCDSM. It’s then the role of the furnishing physician practice to communicate to the payer that all criteria related to AUC consultation have been met. This will be performed through two coding mechanisms. First, coders will be required to append a supplementary HCPCS modifiers to the respective ADI service. Have a look at four of the more common HCPCS modifiers you’ll be working with:

• ME (The order for this service 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 clinical decision support mechanism consulted by the ordering professional)
• MG (The order for this service does not have applicable appropriate use criteria in the qualified clinical decision support mechanism consulted by the ordering professional)
• 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).

In addition to reporting the respective ADI CPT^® code and HCPCS modifier, coders for furnishing providers will be required to include a HCPCS G code that identifies the type of qCDSM utilized by the ordering provider. Some of these G codes include:

• 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)
• G1011 (Clinical Decision Support Mechanism, qualified tool not otherwise specified, as defined by the Medicare Appropriate Use Criteria Program).

FAQ: When does PAMA go into effect?

As it currently stands, the start of 2020 began an “Educational and Operations” testing period. Reporting is technically mandatory at this stage, but failure to report or failure to properly document AUC consultation will not result in any penalties. Beginning on Jan. 1, 2021, however, furnishing providers that fail to report AUC consultation by the ordering provider using the aforementioned HCPCS codes and modifiers will not be reimbursed for the imaging service.

However, questions remain as to whether the use of certain modifiers (MF, MG, MH) will automatically result in a denial from the payer for the furnished service. For instance, the American College of Radiology (ACR) explains in a Q&A session from their “Medicare AUC Mandate – Countdown to Launch!” webinar that it remains to be seen whether the use of modifier MH will result in a denial from CMS and other payers. The ACR expects further elaboration on the use of modifier MH in the 2021 Medicare Physician Fee Schedule (MPFS) Final Rule.

FAQ: Does a provider need to consult a qCDSM for emergency department (ED) patients?

The Centers for Medicare & Medicaid Services (CMS) notes the following exceptions to consulting qCDSM:

• “The ordering professional having a significant hardship exception,
• “Situations in which the patient has an emergency medical condition,” or
• “An applicable imaging service ordered for an inpatient and for which payment is made under Part A.”

FAQ: Do PAMA rules apply to imaging in physician’s offices?

Yes, an ADI performed in a physician’s office must follow the same PAMA protocol as an ADI performed in any of the following additional applicable settings:

• Hospital outpatient departments (including ED)
• Ambulatory surgical centers (ASCs)
• Independent diagnostic testing facilities (IDTFs).

Additionally, CMS outlines the that following payment systems adhere to PAMA guidelines:

• Physician Fee Schedule (PFS)
• Outpatient Prospective Payment System (OPPS)
• ASC Payment System.

FAQ: How can I ensure referring providers follow PAMA protocol?

In order to hit the ground running in 2021, your best bet is to be in contact with the providers that most frequently refer patients for imaging. Ideally, you should be in contact with any and all known referring providers, but the most ideal solution is not always the most practical one.

Fortunately, the ACR provides a template letter that you can mass-distribute to your list of referring providers. Included in this letter is a detailed description of PAMA requirements for compliant ADI referrals.

To ensure a seamless transition between the ordering and furnishing providers, Lindsay Della Vella, COC, medical coding auditor at Precision Healthcare Management in Media, Pennsylvania outlines a few key resources to stay on top of. You may access the aforementioned template and more information on clinical decision support at the following ACR link: https://www.acr.org/Clinical-Resources/Clinical-Decision-Support.

Furthermore, you can go into even greater detail on HCPCS codes, modifiers, and more by navigating through the following MLN Matters Article (MM11268): https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11268.pdf.