Radiology Coding Alert

Providers may no longer need to consult the AUC when modifying orders.

The Medicare Physician Fee Schedule (MPFS) proposed rule for Calendar Year (CY) 2022 was issued on July 13. In the document, you’ll find suggested modifications to the Appropriate Use Criteria (AUC) for advanced diagnostic imaging.

These modifications include how treating physicians or practitioners would handle inaccurate orders, ordering additional services, and reporting any changes to the original order. Read on to learn about the proposed changes to the AUC in the CY 2022 MPFS.

View Proposed Changes to the AUC for Advanced Diagnostic Imaging

The AUC program, implemented by the Protecting Access to Medicare Act of 2014, is designed to help increase the rate of appropriate advanced diagnostic imaging services provided to Medicare beneficiaries. AUC are designed to specify when it is appropriate to perform a procedure, and in order for a procedure to be deemed “appropriate,” the expected health benefits need to greatly exceed the expected health risks. When a practitioner orders an advanced diagnostic imaging service, such as computed tomography (CT) or magnetic resonance imaging (MRI), they “will be required to consult a qualified Clinical Decision Support Mechanism (CDSM) — an electronic portal that determines if the order adheres to AUC or if the AUC consulted does not apply,” says Kristen Taylor, CPC, CHC, CHIAP, Associate Partner at Pinnacle Enterprise Risk Consulting Services in Columbia, South Carolina. The AUC program impacts all physicians, practitioners, and facilities that order or furnish advanced diagnostic imaging services in offices, hospital outpatient departments (e.g., emergency departments), ambulatory surgical centers, and independent diagnostic testing facilities (IDTF).

An ordering professional or furnishing professional is defined in section 1842(b)(18) (C) of the Social Security Act as a:

• Physician
• Physician assistant (PA), nurse practitioner (NP), clinical nurse specialist (CNS)
• Certified registered nurse anesthetist (CRNA)
• Certified nurse-midwife (CNM)
• Clinical social worker
• Clinical psychologist
• Registered dietitian or nutrition professional

Under the Current AUC: According to chapter 15 of the Medicare Benefit Policy Manual (BPM) (Pub. L. 100-02), an interpreting physician, e.g., a radiologist, could receive an order from a treating physician for an MRI, but the patient’s conditions warrant a CT scan. The radiologist may not perform the CT scan until the treating physician provides a new order for the procedure (section 80.6.2). However, if the testing facility is unable to reach the treating physician, then the new procedure may be performed if certain criteria apply (section 80.6.3). Additionally, the radiologist must document the parameters of the new diagnostic test (e.g., the number of views captured), any errors in the order (e.g., requesting a scan of the wrong extremity), and why the patient’s condition would result in the interpreting physician cancelling the test (e.g., cannot perform a chest scan because the patient cannot stand) (section 80.6.4) (URL: www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf).

CY 2022 AUC Modification Proposal: CMS is proposing that the ordering professional or furnishing professional need not consult AUC for conditions where physicians perform additional imaging services in accord with circumstances described in chapter 15 of the BPM. “If an interpreting physician of a testing facility furnishes a diagnostic test to a Medicare beneficiary who is not a hospital inpatient or outpatient, the interpreting physician must document accordingly in their report to the treating physician or practitioner,” Taylor adds.

For these scenarios, CMS is proposing that the “AUC consultation information from the original order is to be reported on the claim line for the additional service(s).” In the case that the furnishing professional modifies the order for an advanced diagnostic imaging service without requesting a new order from the ordering professional, CMS proposes that the AUC consultation information from the ordering professional with the original order “should be reflected on the Medicare claim to demonstrate that the requisite AUC consultation occurred.”

Example: Suppose a primary care physician sends a Medicare patient to your radiology practice for an abdominal ultrasound (76700-76706 Ultrasound, abdominal,…). The radiologist performs this service and sees a suspicious mass. The radiologist then needs a CT scan (74150-74170 Computed tomography, abdomen;…) to determine the nature of the mass. The current AUC program requires the radiologist to go back to the primary care physician with this recommendation, and the primary care physician must order that CT scan. However, with the CY 2022 Proposed Rule, the radiologist would be able to perform the CT scan without waiting for the order as long as they report the original abdominal ultrasound order on the claim line for the additional CT scan service.

According to the American College of Radiologists, “The AUC program will be a valuable tool to ensure that Medicare patients receive the right imaging at the right time” (URL: www.acr.org/-/media/ACR/NOINDEX/Advocacy/2022-MFS-PR-Preliminary-Summary.pdf).

Learn How AUC Program Exceptions Due to the COVID-19 PHE May Be Extended

CMS also acknowledges and understands the hardships that hospitals and medical practices have faced during the Public Health Emergency (PHE). As the AUC program enters the payment penalty phase, CMS would allow AUC program exceptions for significant hardships defined at section 414.94(i) (3) to remain available beyond the PHE expiration date.

The 2022 proposed rule also includes several potential solutions to claims processing issues. These proposed solutions cover ordering professional National Provider Identifier (NPI), critical access hospitals (CAH), the Maryland Total Cost of Care Model, inpatients converted to outpatients, Medicare as a secondary payer, claims denials or returns, and more. The proposed solutions in these areas could help “ensure accurate identification of claims that are and are not subject to the AUC program requirements.”

CMS also proposes starting the AUC claims processing systems edits and payment penalty phase on January 1, 2023, or January 1 of the year after the COVID-19 PHE ends, whichever date is later.