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HBMA RCM Advisor: The Journal of the Healthcare Business Management Association

2020 and Beyond

New Modifiers for Radiology and New Diagnostic Ordering Requirements for All

The specialties you bill for will likely dictate your familiarity with the upcoming requirements associated with ordering and/or billing for advanced diagnostic imaging exams. These new requirements go all the way back to the Protecting Access to Medicare Act of 2014 (PAMA). The act specifically requires the Centers for Medicare and Medicaid Services (CMS) to establish a program to promote ordering providers utilization of appropriate use criteria (AUC) for the advanced diagnostic imaging services of CT, MR, and nuclear medicine exams (including PET). Ordering physicians and practitioners (“ordering professionals”) will be required to consult AUC for all advanced imaging studies billed under the Medicare Physician Fee Schedule (MPFS), the Outpatient Prospective Payment System (OPPS), and the Ambulatory Surgical Center (ASC) Payment System, including those performed in a physician office, hospital outpatient department (including emergency department), IDTF, or ambulatory surgery center. This means if your clients own advanced diagnostic equipment utilized for diagnostic studies, then the consultation and reporting requirements will apply to them as well.

AUC are designed to help clinicians select the most appropriate imaging study for a patient with a particular diagnosis or presenting symptom(s). CMS can only approve AUC that are developed or endorsed by provider-led entities (PLEs) such as national professional medical specialty societies. In most cases, the AUC will be evidence-based. The current listing of qualified PLEs can be found at Once a PLE is listed as qualified, all of the AUC developed or endorsed by that PLE are considered to be “specified AUC” for purposes of the PAMA requirements.

An ordering provider—this can either being the referring physician or clinical staff member when delegated by and under the direction of the referring physician—will access the AUC through a clinical decision support mechanism (CDSM). The CDSM is an electronic portal such as a module in an electronic health record (EHR) or a web-based system. The CDSM will pull information about the patient from the EHR and/or the ordering provider will enter information, and the CDSM will provide immediate feedback about the appropriateness of the proposed imaging exam. The most recent list of qualified CDSMs is available at the CMS website at:

Each CDSM must, at a minimum, include criteria for the following eight priority clinical areas, which are responsible for a significant percentage of advanced imaging exams paid by Medicare:

  • Coronary artery disease (suspected or diagnosed)
  • Suspected pulmonary embolism
  • Headache (traumatic and nontraumatic)
  • Hip pain
  • Low back pain
  • Shoulder pain (to include suspected rotator cuff injury)
  • Cancer of the lung (primary or metastatic, suspected, or diagnosed)
  • Cervical or neck pain

This list will continue to expand in the future.

There are few exceptions to note. The AUC consultation requirement does not apply to imaging exams performed on inpatients and paid under Medicare Part A. It also does not apply to patients with emergency medical conditions as defined by the Emergency Medical Treatment & Labor Act (EMTALA), whether confirmed or suspected, or when the ordering physician or practitioner has received a hardship exception. Any ordering professional experiencing insufficient internet access, EHR or CDSM vendor issues, or extreme uncontrollable circumstances (including natural or manmade disasters) will not be required to consult the AUC using a qualified CDSM. These circumstances will be self-attested at the time of placing the order.

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While initially there will be no repercussions to the ordering providers for the studies that they order, eventually CMS will identify the top 5% of ordering professionals who are consistently failing to follow AUC recommendations for studies involving priority clinical areas outlined above. Under PAMA, these “outliers” will be required to obtain prior authorization for any advanced imaging studies they wish to order for Medicare patients. This is very important to note: Your clients do not want to fall into the top 5% and have to obtain prior authorization for all of their advanced imaging studies. This will create additional work for their staff and potentially cause delays for Medicare patients to receive imaging services.

While this is ultimately a regulatory requirement, there is a bright side. Taking the time to perform the AUC consultation is defined by CMS as a High-Weight Improvement Activity for the Medicare Access and CHIP Reauthorization Act (MACRA) quality program. Additionally, this activity is eligible for 10% bonus points in the Promoting Interoperability (PI) performance category. Also, the Cost Display for Laboratory and Radiologic Orders is defined as a Medium-Weight Improvement Activity, which is also eligible for a 10% bonus points award in the PI performance category

For the Interpreting Providers (radiologists and any others interpreting advanced imaging studies)
While the implementation for AUC has been a work in progress for several years as CMS has rolled out the PLEs, CDSMs, etc., the biggest questions around how to bill for services remained unanswered until recently. On July 26, 2019, CMS released the official requirements for 2020 and beyond. Currently, AUC implementation is in a voluntary phase that began July 1, 2018, and ends Dec. 31, 2019. Jan. 1, 2020, ushers in the testing and operations testing period. During this time, assuming medical necessity is met, CMS will pay for advanced imaging studies regardless of whether they meet appropriateness criteria during the consultation process, nor will CMS deny any claims based solely on the submission of AUC reporting criteria. Beginning Jan. 1, 2021, this will change, as CMS will deny payment to both the facility that provided the imaging and the interpreting provider if the required AUC elements such as G-codes and modifiers are not reported.

Beginning Jan. 1, 2020, CMS has indicated claims processing systems will be prepared to accept claims with Current Procedural Terminology (CPT®) or HCPCS C code, for advanced diagnostic imaging along with a line item HCPCS modifier. The modifier will identify what level of the AUC was followed or to identify an exception to the program. Table 1 includes the modifiers for reporting under the AUC.

CMS has also provided the full list of HCPCS advanced imaging procedure codes, which are includes in the AUC program. This can be reviewed in the MLN Matters MM11268, Table 3 lists the HCPCS codes included in the AUC program as provided by CMS beginning Jan. 1, 2020. Note that this table does not include any new 2020 CPT® codes, so you will need consult an updated chart after the beginning of the year (or whenever CMS releases).

Even though 2020 is a testing year, and there will be no financial impact to the claims submitted to CMS for advanced diagnostic imaging service, it is vital all ordering professionals be aware of the program requirements and commit to their role in the program. It is equally important imaging facilities and interpreting physicians ensure their role in accurately reporting the modifiers and G-codes provided is also performed. This is yet another example where you can work collaboratively with your clients to ensure that they are up to date and ready for required regulatory requirements. Even though 2020 is a testing year, it is the best course of action to get started sooner rather than later since many organizations will require system and operational changes to be compliant Jan. 1, 2021. Remember the best defense is a good offense.

Melody W. Mulaik, MSHS, is the president of Coding Strategies Inc. and Revenue Cycle Inc. She is a frequent speaker and author for nationally recognized professional organizations and publications. Mulaik’s areas of expertise include coding and compliance, management engineering, and operations improvement, and she is nationally recognized for her extensive radiology expertise.







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