One of the cornerstones of the Protecting Access to Medicare Act of 2014 was the development of an appropriate use criteria (AUC) program that requires doctors to consult a qualified clinical decision support mechanism (qCDSM) when ordering advanced imaging services for Medicare patients. As many in the revenue cycle management (RCM) world already know, CMS was scheduled to start penalizing providers who don’t participate in the AUC program on Jan. 1, 2022. The COVID-19 pandemic, however, led to such actions being delayed until 2023 at the earliest.
The latest CMS data suggest that preparation for AUC has been slow going for many healthcare providers. Consider, for example, that just 9% of CY2020 claims subject to AUC policies were submitted with enough relevant data. The delay in AUC penalties represents a significant opportunity for providers to integrate, educate and test AUC workflows to ensure as little disruption as possible takes place when the payment penalty phase officially (eventually) goes into effect.
Now would be the perfect time to ensure your RCM and integration teams are up to date on the latest CMS policies. Read below for six important takeaways from the CY2022 Final Rule that everyone in RCM should know and understand.
1. Modifying imaging orders
CMS stated clearly in its final rule that modifying orders for advanced imaging services do not require a new consult and those claims should be appended with the original consult data.
2. How to juggle multiple NPIs
Claims may need to be submitted separately when multiple orders for advanced imaging are obtained for a single patient encounter. CMS addressed in its final rule that furnishing professionals will need to submit claims separately when AUC data pertains to more than one referring/ordering National Provider Identifier (NPI).
The only exception to this rule is for claims filed on form 837P.
3. Know your modifiers
CMS has clarified in the CY2022 final rule that exception and hardship modifiers should not be used on imaging orders for clinical trials, new physicians, low-volume facilities, second opinions or by using attestation. Instead, the ordering professional will need to consult their qCDSM on a case-by-case basis. The current list of applicable exception and hardship modifiers can be found on the CMS MLN Matters Number: MM11268. For example, cases affected by extreme and uncontrollable circumstances should use an MD modifier for each order effected. Even in prolonged instances, CMS has stated attesting a specific time frame for these scenarios is not valid.
4. Filing claims under alternative payment models
One of the biggest challenges CMS will face when implementing its AUC program is the evaluation of alternative payment and service delivery models. The Maryland Total Cost of Care Model, for instance, sets a limit on Medicare costs for all providers in the state of Maryland, with a goal of saving more than $1 billion in healthcare costs by its fifth year. Critical access hospitals, on the other hand, are exempt from the AUC program altogether, adding additional complications for CMS.
The agency hopes to organize these alternative scenarios by using CMS certification numbers on each claim as opposed to using modifier MH as originally considered. When filing claims for either one of these models, make sure you use the correct bill; AUC edits will be applied to bill type 13X, the same one used for traditional outpatient claims.
5. Goodbye, modifiers
The industry had hoped it could bypass denials by continuing to use the MH modifier when it is unclear if an ordering professional consulted their qCDSM, and the QQ modifier when it is unclear if the ordering professional’s requested imaging adheres to the qCDSM. However, CMS has stated it will sunset modifiers MH and QQ once financial penalties go into effect.
With this in mind, it will be imperative that front-end staff are trained to reach out and obtain any missing AUC data prior to imaging to avoid financial penalties.
6. Return to sender
Once penalties are live, CMS says it will not automatically deny claims that do not satisfy AUC requirements; instead, such claims will be returned for an immediate correction. It’s yet another reason why providers, especially RCM specialists, need to make sure they understand the ins and outs of this formidable new policy. If at first you don’t succeed, you will be asked to try (and try) again.
If you are a current vRad client and would like to discuss your integration options with vRad in preparation for AUC, please contact firstname.lastname@example.org.