Appropriate Use Criteria for Advanced Diagnostic Imaging Services

Thoughtware Alert Dec 09, 2019
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On January 1, 2020, CMS will begin the testing period of the new Appropriate Use Criteria (AUC) program for advanced diagnostic imaging services. Full implementation will be effective January 1, 2021. According to the Protecting Access to Medicare Act of 2014 (PAMA), providers are required to order the most appropriate tests for their patient needs. Providers will be required to:

  1. Perform an AUC consultation in a CMS-approved, provider-based outpatient setting. See CMS’ recent MLN Matters® article for the list of CMS-approved settings.
  2. Consult the electronic Clinical Decision Support Mechanism (CDSM) portal prior to ordering services to determine if AUC is applicable. Visit CMS’ website for a full list of approved CDSMs.
  3. Append the appropriate Current Procedural Terminology (CPT) codes (G1000-G1011) and modifiers (MA-MH and QQ) to claims beginning January 1, 2020. CMS has provided a list of the radiology and nuclear CPT codes that will be affected by these changes.

Organizations are encouraged to use these new reporting codes during the program’s testing phase, and claims won’t be denied for failing to include AUC-related information or for misreporting AUC information on nonimaging claims. The claims processing systems will be prepared by January 1, 2020, to accept claims that contain these new requirements. Facilities should validate their billing systems are accepting the newly developed codes and modifiers.

AUC Timetable

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