CHA News

CMS Establishes Claims Processing Requirements for Appropriate Use Criteria Program

For CFOs, CMOs

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The Centers for Medicare & Medicaid Services (CMS) recently instructed Medicare Administrative Contractors to accept modifier codes for appropriate use criteria (AUC) on Medicare claims for advanced diagnostic imaging services beginning Jan. 1, 2020.

As required by the Protecting Access to Medicare Act of 2014, professionals and facilities furnishing advanced diagnostic imaging services under the physician fee schedule, or the outpatient prospective payment or ambulatory surgical center prospective payment systems will be required — by 2021 — to report consultation of AUC by the ordering clinician on the claim. CMS has established 2020 as a testing and educational year, under which Medicare will continue to pay claims that do not include the consultation information. Currently, hospitals can voluntarily report AUC consultation on the claim using the “QQ” modifier.