Appropriate Use Criteria

Effective January 1, 2020, the Protecting Access to Medicare Act (PAMA) requires referring providers to consult appropriate use criteria (AUC) prior to ordering advanced diagnostic imaging services (ADIS) including CT, MR, Nuclear Medicine and PET. It is important to note that the law does not mandate ordering providers to strictly adhere to the AUC, just consult AUC.

An AUC consult via a Centers for Medicare and Medicaid Services (CMS) qualified clinical decision support mechanism (qCDSM) must be documented. Without a documented consult, rendering providers (both facilities and radiologists) will not receive Medicare payment for the procedure. CMS finalized an “education and operations testing period” that will run from January 1, 2020 through December 31, 2020, where there will be no penalties for incorrect reporting.

Note that while integrated CDS systems may be incorporated into your current EHR system workflow, RIA offers a free online portal qCDSM option called Careselect that may be used at no cost to you.

Radiology practices are required to report which qCDSM was consulted, the results of the consultation (adhere, not adhere or not applicable) and the NPI of the referring physician. CMS has created a series of G-codes and modifiers to report this information on advanced diagnostic imaging claims. We ask that you please provide this information to our office when ordering advanced diagnostic imaging studies in order to avoid unnecessary delays in patient care starting January 1, 2020.

Modifier

Purpose

Does it need a G-Code?

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

NO

MB

Ordering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of insufficient internet access

NO

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

NO

MD

Ordering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of extreme and uncontrollable circumstances

NO

ME

The order for this service adheres to the appropriate use criteria in the clinical decision support mechanism consulted by the ordering professional

YES

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

YES

MG

The order for this service does not have appropriate use criteria in the clinical decision support mechanism consulted by the ordering professional

YES

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

NO

QQ

Ordering professional consulted a qualified clinical decision support mechanism

N/A

 

G-Codes – These indicate which CDSM was consulted, these are to be used in conjunction with HCPCS codes ME, MF, and MG.

G-Code

CDSM

G1000

Clinical Decision Support Mechanism Applied Pathways, as defined by the Medicare Appropriate Use Criteria Program

G1001

Clinical Decision Support Mechanism eviCore, as defined by the Medicare Appropriate Use Criteria Program

G1002

Clinical Decision Support Mechanism MedCurrent, as defined by the Medicare Appropriate Use Criteria Program

G1003

Clinical Decision Support Mechanism Medicalis, as defined by the Medicare Appropriate Use Criteria Program

G1004

Clinical Decision Support Mechanism National Decision Support Company, as defined by the Medicare Appropriate Use Criteria Program

G1005

Clinical Decision Support Mechanism National Imaging Associates, as defined by the Medicare Appropriate Use Criteria Program

G1006

Clinical Decision Support Mechanism Test Appropriate, as defined by the Medicare Appropriate Use Criteria Program

G1007

Clinical Decision Support Mechanism AIM Specialty Health, as defined by the Medicare Appropriate Use Criteria Program

G1008

Clinical Decision Support Mechanism Cranberry Peak, as defined by the Medicare Appropriate Use Criteria Program

G1009

Clinical Decision Support Mechanism Sage Health Management Solutions, as defined by the Medicare Appropriate Use Criteria Program

G1010

Clinical Decision Support Mechanism Stanson, as defined by the Medicare Appropriate Use Criteria Program

G1011

Clinical Decision Support Mechanism, qualified tool not otherwise specified, as defined by the Medicare Appropriate Use Criteria Program

 

We wish to be an ongoing resource for you during this implementation process. We expect additional resources to be released by CMS soon. Further information can be found on the American College of Radiology website.

To register for the free qCDSM through CareSelect Imaging Open Access Portal least click here.

If you already have a CareSelect Imaging Open Access Portal account, click here to log in.

Clinical Decision Support Portal

CareSelect Imaging Open Access Login

To begin using Open Access, you will need to complete an online registration form. Navigate to http://openaccess.careselect.org/registration to begin the registration process.

On the registration page, create an account and provide basic information including name, e-mail, NPI, and a few other informational details.

After submitting the registration, confirm your account by following directions as outlined in the confirmation email.

The last step of the registration process before gaining access to the AUC content will be accepting the End User Licensing Agreement.

CareSelect Imaging Open Access is available to you free of cost. For a demo, navigate to https://qcdsm.nationaldecisionsupport.com/.

AUC Consultation Process

As an ordering provider, you will need to consult CDS for advanced diagnostic imaging orders (CT, MR, NM, PET) at the point of ordering. This includes selecting an imaging exam and a clinical indication that best describes your patient’s clinical scenario. At the end of your CDS consultation, you will be provided with a HCPCS Code (i.e. G-Code) and HCPCS Modifier, which must be recorded on the order sent to RIA.

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