Radiology Coding Alert

Reimbursement:

Understand How These AUC Program Changes Will Affect Your Practice in 2022

Published on Tue Dec 21, 2021

Providers won’t receive penalties in 2022 due to the pandemic.

Radiology practices can rest easy knowing Medicare has delayed the penalty phase of the Appropriate Use Criteria (AUC) program due to the COVID-19 public health emergency (PHE). Additionally, practices can continue to attest to significant hardships caused by the pandemic.

The Centers for Medicare and Medicaid (CMS) finalized their proposed revisions to the AUC program for advanced diagnostic imaging services in the Calendar Year (CY) 2022 Medicare Physician Fee Schedule (MPFS). Issued on Nov. 2, 2021, the MPFS also finalized guidance on when providers need to consult the AUC for order modifications. Continue reading to learn about the changes to the AUC program.

Delaying Penalties Due to the COVID-19 PHE

Arguably one of the most important pieces of information in the final rule regarding the AUC program is CMS’ decision to delay the payment penalty phase. Earlier in 2021, CMS proposed delaying the AUC program penalty phase until Jan. 1, 2023, or the first of the year following the declared end of the COVID-19 PHE. The delay is due to the PHE and allows providers additional time to prepare for the payment penalty phase, as several practitioners had to reallocate resources during the pandemic.

During the public comment period, CMS solicited feedback on the proposal to delay the implementation of the payment penalty phase, asking whether they have “appropriately taken into account the PHE for COVID-19 and other factors.”

After reviewing the public comments, CMS finalized the proposal to delay the payment penalty phase of the AUC program until Jan. 1, 2023, or the first of the year following the declared end of the COVID-19 PHE, whichever is later.

Report Significant and Uncontrollable Hardships

CMS described “extreme and uncontrollable circumstances” in the CY 2019 MPFS that have negatively affected healthcare operations, communication systems, or area infrastructure. The circumstances are events that are completely out of the ordering professional’s control that can prevent the professional from consulting AUC through a qualified clinical decision support mechanism (CDSM). Clinicians have the flexibility to identify extreme and uncontrollable circumstances that qualify as hardship criteria under the AUC program.

One such extreme and uncontrollable circumstance is the COVID-19 PHE, which has been in effect since Jan. 27, 2020. Stakeholders who attested to significant hardships under the AUC program due to the circumstances around the COVID-19 PHE may continue to self-attest for significant hardship exceptions as the AUC program moves into the payment penalty phase.

Additionally, CMS acknowledged that significant hardships related to or relating from the PHE may extend beyond the expiration of the PHE and indicated that “AUC program exceptions will continue to be available for such significant hardships,” which include “insufficient internet access; (electronic health record) or CDSM vendor issues; or extreme or uncontrollable circumstances.”

Understand How Radiologists Can Modify Imaging Orders

In the CY 2022 MPFS proposed rule, CMS proposed 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 Medicare Benefit Policy Manual (BPM). Chapter 15, sections 80.6.1-4 of the BPM state that an interpreting physician or testing facility may not perform an additional imaging service that differs from what was included on the original order until the treating physician or practitioner provides a new order.

“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,” says Kristen Taylor, CPC, CHC, CHIAP, Associate Partner at Pinnacle Enterprise Risk Consulting Services in Columbia, South Carolina.

According to chapter 15 of the BPM, the interpreting physician needs to document the following information in the patient’s medical record:

Treating physician/practitioner cannot be reached;
Ordered test is performed and additional service is medically necessary due to the original test’s abnormal result;
Delaying the additional service could cause an adverse effect on the patient’s care;
Additional test’s result is delivered to and used by the treating physician/practitioner in the patient’s treatment; and
Interpreting physician/practitioner documents the reasons for the additional services in the report.

Scenario: A general practitioner refers a Medicare patient to your radiology practice for lung X-rays (71045-71048 Radiologic examination, chest; …). The radiologist performs the X-rays and sees a suspicious mass. The radiologist then needs a CT scan (71250-71271 Computed tomography, thorax…) to determine the nature of the mass.

In this scenario, under the final rule the radiologist can perform the CT scan without having to wait for a new order, as long as they report the original X-ray order on the claim line for the additional CT scan service.

Why? In the CY 2022 MPFS final rule, CMS finalized their proposal to allow the treating physician or practitioner — also referred to as the furnishing professional — to modify the advanced diagnostic imaging services order by replacing the original ordered service or performing additional imaging service(s) when they are unable to reach the ordering professional for a new order. The furnishing professional must also append the AUC consultation information provided by the ordering professional on the original order to the Medicare claim for the services performed.

The final rule was published in the Federal Register on November 19, 2021, and is available at www.federalregister.gov/documents/2021/11/19/2021-23972/medicare-program-cy-2022-payment-policies-under-the-physician-fee-schedule-and-other-changes-to-part.