Billing and Coding: Medicare to Mandate Appropriate Use Criteria for Advanced Imaging
By John Verhovshek, MA, CPC
Radiology Today
Vol. 19 No. 6 P. 8

Within the next several years, providers will be required to observe appropriate use criteria (AUC) as a condition of payment when reporting "advanced diagnostic imaging services" for Medicare beneficiaries. Beginning in July 2018, the Centers for Medicare & Medicaid Services (CMS) will encourage the use of AUCs through a voluntary reporting program.

Defining AUC
The American Academy of Orthopaedic Surgeons defines AUC as follows: "[AUC] specify when it is appropriate to use a procedure. An 'appropriate' procedure is one for which the expected health benefits exceed the expected health risks by a wide margin. Often, sound data is not available or does not provide evidence that is detailed enough to apply to the full range of patients seen in everyday clinical practice. Nevertheless, physicians must make daily decisions about when to use or not use a particular procedure. AUC facilitate these decisions by combining the best available scientific evidence with the collective judgment of physicians in order to determine the appropriateness of performing a procedure."

Additionally, in the 2016 Physician Fee Schedule final rule, CMS defined AUC as follows: "[AUC] means criteria only developed or endorsed by national professional medical specialty societies or other provider-led entities, to assist ordering professionals and furnishing professionals in making the most appropriate treatment decision for a specific clinical condition for an individual. To the extent feasible, such criteria must be evidence based. An AUC set is a collection of individual [AUC]. An individual criterion is information presented in a manner that links: a specific clinical condition or presentation, one or more services, and an assessment of the appropriateness of the service(s)."

Succinctly stated, AUC are meant to guide health care providers' treatment decisions to maximize patient outcomes, while minimizing inappropriate or ineffective utilization of services.

How AUC Are Linked to Medicare Payment
The Protecting Access to Medicare Act of 2014 (PAMA) established a program that requires health care providers to adhere to AUC when ordering "advanced diagnostic imaging services" for Medicare beneficiaries. Practitioners access AUC through an electronic portal called a clinical decision support mechanism (CDSM). CMS requires that a CDSM be "qualified" for compliance under PAMA. You can find a list of qualified CDSMs on the CMS website.

Voluntary Reporting of AUC Consults Is About to Begin
Full implementation of PAMA is expected in early 2020; however, beginning July 1, 2018, ordering providers may voluntarily report their consultation of AUC through a qualified CDSM by appending modifier QQ (ordering professional consulted a qualified CDSM for this service and the related data were provided to the furnishing professional) to their claims. As detailed in MLN Matters 10481, the following criteria apply to modifier QQ:

• It is used when the furnishing professional is aware of the result of the ordering professional's consultation with a CDSM for that patient.

• It is reported on both the facility and professional claim.

• It is reported on the same claim line as the CPT code for an advanced diagnostic imaging service furnished in an applicable setting and paid for under an applicable payment system.

A list of affected applicable CPT codes, to which modifier QQ may be appended, may be found in CMS Transmittal 2040. They include the following:

• MRI: 70336, 70540, 70542, 70543, 70544, 70545, 70546, 70547, 70548, 70549, 70551, 70552, 70553, 70554, 70555, 71550, 71551, 71552, 71555, 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72159, 72195, 72196, 72197, 72198, 73218, 73219, 73220, 73221, 73222, 73223, 73225, 73718, 73719, 73720, 73721, 73722, 73723, 73725, 74181, 74182, 74183, 74185, 75557, 75559, 75561, 75563, 75565, and 76498.

• CT: 70450, 70460, 70470, 70480, 70481, 70482, 70486, 70487, 70488, 70490, 70491, 70492, 70496, 70498, 71250, 71260, 71270, 71275, 72125, 72126, 72127, 72128, 72129, 72130, 72131, 72132, 72133, 72191, 72192, 72193, 72194, 73200, 73201, 73202, 73206, 73700, 73701, 73702, 73706, 74150, 74160, 74170, 74174, 74175, 74176, 74177, 74178, 74261, 74262, 74712, 74713, 75571, 75572, 75573, 75574, 75635, 76380, and 76497.

• Single-Photon Emission CT: 76390.

• Nuclear Medicine: 78012, 78013, 78014, 78015, 78016, 78018, 78020, 78070, 78071, 78072, 78075, 78099, 78102, 78103, 78104, 78110, 78111, 78120, 78121, 78122, 78130, 78135, 78140, 78185, 78191, 78195, 78199, 78201, 78202, 78205, 78206, 78215, 78216, 78226, 78227, 78230, 78231, 78232, 78258, 78261, 78262, 78264, 78265, 78266, 78267, 78268, 78270, 78271, 78272, 78278, 78282, 78290, 78291, 78299, 78300, 78305, 78306, 78315, 78320, 78350, 78351, 78399, 78414, 78428, 78445, 78451, 78452, 78453, 78454, 78456, 78457, 78458, 78459, 78466, 78468, 78469, 78472, 78473, 78481, 78483, 78491, 78492, 78494, 78496, 78499, 78579, 78580, 78582, 78597, 78598, 78599, 78600, 78601, 78605, 78606, 78607, 78608, 78609, 78610, 78630, 78635, 78645, 78647, 78650, 78660, 78699, 78700, 78701, 78707, 78708, 78709, 78710, 78725, 78730, 78740, 78761, 78799, 78800, 78801, 78802, 78803, 78804, 78805, 78806, 78807, 78811, 78812, 78813, 78814, 78816, and 78999.

Applicable settings for the use of modifier QQ currently include physician offices, hospital outpatient departments, and ambulatory surgical centers.

For now, Medicare administrative contractors will continue to pay claims for services listed above, regardless of whether the ordering provider followed AUC as accessed via a qualified CDSM and regardless of whether modifier QQ is appended. When PAMA is fully implemented, however, providers who order advanced imaging services in the absence of, or contrary to, AUC may be subject to nonpayment of claims and prepayment review.

— John Verhovshek, MA, CPC, is the managing editor of AAPC.