Claims Processing Details Released for AUC Mandate – a Call to Action (continued…)!

By Nathan Baugh 

Last month, the Centers for Medicare & Medicaid Services (CMS) released a Medicare Learning Network Article (MLN Matters) detailing certain claims processing aspects of the Appropriate Use Criteria (AUC) Mandate.

On February 20, 2020, CMS revised the MLN Matters article (SE20002) to include a list of additional Qualified Clinical Decision Support Mechanisms (qCDSMs) and their corresponding G-codes which will become effective on 4/1/20:

CMS also made some minor clarifications in the 2/20/20 update. Specifically, CMS clarified that the use of the K3 segment (for institutional claims) to report the ordering professional’s NPI is only for electronic claims. CMS instructs billers to contact the NUBC (National Uniform Billing Committee) for information on reporting ordering professional’s NPI on paper claims.

This article (SE20002) provides guidance for processing claims for certain institutional claims (UB-04) that are subject to the AUC program for advanced diagnostic imaging services. CMS began to accept claims with AUC information as of January 1, 2020. This marked the beginning of the education and operations testing period for the AUC program. While there will not be payment penalties during this period, stakeholders and CMS can use this time to practice reporting and accepting AUC information on claims.

All imaging departments that use institutional claims (UB-04) should make sure that the billing and IT staff they work with have this document.

Some of the claims processing details explored in this document include:

1-How to report ordering professional information on institutional claims;

2-Which revenue codes to use on the lines that contain the qCDSM G-codes;

3-An example of how to report multiple consultation by the same ordering provider; and

4-An example of how to report multiple services ordered by different ordering providers with different CDSMs.

The article contains ten different examples of AUC claims scenarios and should be reviewed by all imaging departments billing on the institutional claim form.

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.