At the end of July, Medicare released a set of modifiers that you need to know if you’re involved in ordering or coding for imaging. The modifiers, effective Jan. 1, 2020, are part of Medicare’s changes related to Appropriate Use Criteria (AUC) for advanced diagnostic imaging services. Check out the AUC-related modifiers below and then read on to brush up on this program.
Find These M Modifiers to Prep Now
The modifiers below are available from CMS Transmittal 2323, CR 11268, from MLN Matters article MM11268, and from the CMS HCPCS quarterly update page in the file named Revised Other New Codes Published 7-26-2019 Effective 10-1-2019 and 1-1-2020:
- 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 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).
You may recognize these as similar to modifier QQ (Ordering professional consulted a qualified clinical decision support mechanism for this service and the related data was provided to the furnishing professional), which was effective July 1, 2018.
Get an Overview of the AUC Program
If you aren’t sure how to use these modifiers, the transmittal link in the previous section is a good place to start. Here’s a quick summary.
The Protecting Access to Medicare Act (PAMA) of 2014 created a program to improve the rate of appropriate advanced diagnostic imaging services (such as CT, PET, MRI, and nuclear medicine) for Medicare patients.
The program requires ordering providers to consult a qualified clinical decision support mechanism (CDSM) when ordering an advanced imaging service furnished in an applicable setting (office, hospital outpatient department or emergency department, ASC, IDTF) and paid under an applicable payment system (physician fee schedule, hospital OPPS, ASCs).
What’s a CDSM? A CDSM is an electronic tool that provides AUC information to the clinician to help with making the most appropriate decision for the patient during workup. The CDSM will state whether an order does or does not adhere to AUC or if there is no applicable AUC. The CDSM can be a module in the electronic health record (EHR), a separate mechanism, or one established by CMS. Medicare lists qualified CDSMs on its site.
Use 2020 to Iron Out Reporting Wrinkles
Jan. 1, 2020, is the start of the Educational and Operations Testing Period, with full implementation expected Jan. 1, 2021 (right when you have to start implementing those massive E/M changes, too).
The future goal for the program is that ordering professionals with outlier ordering patterns will have to get prior authorization.
For 2020, Medicare states “claims will not be denied for failing to include AUC-related information or for misreporting AUC information on non-imaging claims,” but Medicare encourages use of the AUC-related codes and modifiers so providers get practice and Medicare gets trackable information during the test phase.
Know Which Modifiers Require Extra G Code
If you’re reporting the advanced diagnostic imaging service (you can view the specific codes in Transmittal 2323), you should append the appropriate AUC-related modifier to that imaging code.
If you append ME, MF, or MG, you also should report a G code (or G codes) from G1000-G1011 on that claim to indicate which CDSM the ordering provider consulted. And that, of course, means that ordering providers must have a method of reliably communicating the required information to radiology coders.
Note: The AUC-related G codes will get a denial message, so don’t be surprised to see a message for your claim about the code being informational and non-payable.
What About You?
Does your organization plan to use the CDSM or report AUC-related codes and modifiers? What plan do you have for communication between ordering providers and radiology teams?