CMS Releases New Information on Appropriate Use Criteria to MACs. AUC Information will NOT be Required on Claims in 2020

Posted by

By Nathan Baugh 

The Centers for Medicare & Medicaid Services (CMS) is releasing key information regarding the Appropriate Use Criteria (AUC) program via “guidance” this year (as opposed to rulemaking). Friday, we received the first of these guidance documents via a Change Request (CR) designed to inform Medicare Administrative Contractors (MACs) that they need to start accepting AUC related modifiers and HCPCS codes on claims in 2020.

The biggest question our community had going into 2020 was around the Educational and Operational Testing Period which lasts for the full calendar year. Specifically, we wanted to know exactly what CMS meant by their statement that “claims will not be denied for incorrect AUC information.” Does this mean that claims with NO AUC information will still be paid? Or, does CMS expects some AUC information on each claim and will simply not deny the claim if that information is incorrect?

Friday we got our answer.

“…claims will not be denied for failing to include AUC-related information or for misreporting AUC information.”

While AUC-related information may be absent from imaging claims in 2020, CMS writes that they expect ordering professionals to begin consulting qualified Clinical Decision Support Mechanisms (qCDSM) and providing information to the furnishing providers. According to CMS, “even though claims will not be denied during this Educational and Operations Testing Period inclusion is encouraged as it is important for CMS to track this information.”

CMS also released a significant amount of technical information regarding which advanced imaging codes are expected to have AUC consultations, the specific G-codes (for the qCDSM used) and modifier codes (for the result of the consultation). CMS created different modifier codes for the various exceptions to the AUC policy including: emergency medical conditions, insufficient internet access, electronic health record issues, extreme and uncontrollable circumstances.

The modifiers ME, MF, and MG indicate to CMS that the order adhered, did not adhere, or was not applicable to the AUC respectively.

Of particular note for the AHRA community, CMS created a modifier code (MH) which can be used to indicate that it is unknown if the ordering professional consulted AUC because information was not conveyed to the furnishing professional. The full description of each modifier code is below.

While this CR did contain answers to some of our biggest questions, there are still aspects of the program that need clarification. For instance, it is still unclear exactly where the ordering professional’s NPI should go on both the CMS-1450 (UB-04) and the CMS-1500 claim forms as well as their electronic equivalents. Moreover, it is still unclear how CMS expects us to report information from multiple ordering professionals using multiple qCDSM systems.

CMS states that a subsequent CR will follow at a later date that will further operationalize the AUC policy. We will be sure to report on that information as soon as it is released.

HCPCS Modifier Codes:

MA     Ordering professional is not required to consult a clinical decision support mechanism due to service being rendered to a patient with a suspected or confirmed emergency medical condition

MB      Ordering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of insufficient internet access

MC     Ordering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of electronic health record or clinical decision support mechanism vendor issues

MD     Ordering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of extreme and uncontrollable circumstances

ME      The order for this service adheres to the 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 qualified clinical decision support mechanism consulted by the ordering professional

MG     The order for this service does not have appropriate use criteria in the 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

QQ      Ordering professional consulted a qualified clinical decision support mechanism for this service and the related data was provided to the furnishing professional (effective date: 7/1/18)

G codes:

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

G1003 Clinical Decision Support Mechanism Medicalis, as defined by the Medicare Appropriate Use Criteria Program

G1004 Clinical Decision Support Mechanism National Decision Support Company, as defined by the Medicare Appropriate Use Criteria Program

G1005 Clinical Decision Support Mechanism National Imaging Associates, as defined by the Medicare Appropriate Use Criteria Program

G1006 Clinical Decision Support Mechanism Test Appropriate, as defined by the Medicare Appropriate Use Criteria Program

G1007 Clinical Decision Support Mechanism AIM Specialty Health, as defined by the Medicare Appropriate Use Criteria Program

G1008 Clinical Decision Support Mechanism Cranberry Peak, as defined by the Medicare Appropriate Use Criteria Program

G1009 Clinical Decision Support Mechanism Sage Health Management Solutions, as defined by the Medicare Appropriate Use Criteria Program

G1010 Clinical Decision Support Mechanism Stanson, 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

Also, see this recent mln Matters article as an additional resource. These articles explain national Medicare policy in an easy-to-understand format.


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 baughn@capitolassociates.com.

Post a Comment

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s