By Nathan Baugh
On November 1st, the Centers for Medicare and Medicaid Services (CMS) released the 2019 Physician Fee Schedule (PFS) Final Rule. The PFS rule is released every year and is the document through which CMS first proposes and then finalizes all regulations regarding the Appropriate Use Criteria (AUC) policy. If you need a refresher on what the AUC policy is, please take a look at AHRA’s infographic on AUC here.
CMS is largely holding steady on their AUC policy in this year’s PFS final rule. After delaying the start date for several years, CMS appears committed to the timeline they established last year. The “voluntary” phase is underway and lasts until January 1, 2020, upon which time the year-long “educational and operational testing” phase begins. In 2020, CMS expects applicable advanced imaging claims to include AUC information, but will not deny claims for failure to include proper AUC consultation information. On January 1st, 2021, final implementation of the AUC program begins.
In this final rule, CMS recommits to their initial approach for AUC reporting. After abandoning the concept in last year’s rulemaking cycle, CMS has re-proposed (and now finalized) a system whereby AUC information will be reported on claims through G-codes and modifiers. The Clinical Decision Support Mechanism (CDSM) used by the ordering professional to consult Appropriate Use Criteria sets will be represented by “yet to be created” G-codes. The result of that consultation: adhere, did not adhere, or not applicable, will be indicated on claims in the form of “yet to be” created modifiers.
Modifier codes will also be used to indicate exemptions from AUC policy such as the hardship exception or imaging services ordered for individuals with an emergency medical condition as defined in 1867(e)(1) of the Social Security Act.
Applicable advanced imaging claims must also include the ordering professional’s National Provider Identifier (NPI) number. CMS has not yet identified where this will go on the furnishing facility claim or how this information will crosswalk to electronic claims, but they are aware that they need to address this in the next cycle of rulemaking.
AHRA, along with many other groups in the imaging space felt that a unique consultation identifier (UCI) or “smart” number would represent a better solution to AUC reporting, but CMS felt that there were too many issues with that approach to have things ready in time for 2020. CMS does leave the door open for a future switch to a UCI system, but they note in the final rule that “the prospect of developing and using a UCI is not a realistic immediate solution.”
One area that CMS did amend their proposed rule was in regards to who may consult AUC through the qualified CDSM (qCDSM). In the proposed rule, CMS stated that “auxiliary personnel” incident to the ordering professional’s services could perform the AUC consultation on the ordering professional’s behalf. There were many who felt that the term auxiliary personnel was too broad and could include administrative personnel. However, in the final rule, CMS backed off of this policy. Instead, CMS finalized that only clinical staff under the direction of the ordering professional may perform the AUC consultation with a qCDSM.”
CMS uses the definition of clinical staff as defined by American Medical Association which is: “Persons who work under the supervision of a physician or other qualified health care professions and who is allowed by law, regulation, and facility policy to perform or assist in the performance of a specified professional service, but who does not individually report that professional service.”
Despite several years of rulemaking, there are still aspects of the AUC policy that need further clarification. For instance, CMS has not yet developed how they will audit providers to ensure compliance with the AUC policy or as CMS puts it “program monitoring activities.” AHRA firmly believes that furnishing professionals (radiologists) should be held harmless if the ordering professional conveys incorrect AUC information on an order. While CMS did not go into a great amount of detail on this notion of holding furnishing providers harmless, they did write that they “will take into account the specific roles of ordering and furnishing professionals and facilities as the program develops and we begin to engage in program monitoring activities.”
Please be sure to check the AHRA Advocacy page for updates throughout 2019 as AHRA monitors the final year of rulemaking prior to the start of the “educational and operational testing” phase in 2020.
Nathan Baugh is an associate with Capitol Associates, Inc., a government relations/consulting firm based in Washington, DC, who has partnered with AHRA on their regulatory affairs issues. He can be reached at firstname.lastname@example.org.