[PDF] Is Your Organization Ready for AUC Implementation? Melody W PDF Is-Your-Organization-Ready-for-AUC-and-CDS-Implementation.pdf

Indicates newly qualified PLEs as of June 30, 2019 6 https://www cms gov/ Table 1 HCPCS Modifiers for AUC Program HCPCS (ABN) is required? 32 32

ABN claim reporting modifiers ○ When not to use an advance written notice of noncoverage ○ Resources TYPES OF ADVANCE WRITTEN NOTICES OF

[PDF] Items Submitted With a GZ Modifier - CMS Manual System

4 fév 2011 · automatically deny claim line(s) items billed with the GZ modifier The GZ modifier indicates that an ABN was not issued to the beneficiary and

[PDF] Modifiers GA, GX, GY, and GZ - Moda Health

5 mai 2014 · (CMS 1) In this memo CMS instructed: • An advanced beneficiary notice of non- coverage (ABN) is to be used for Medicare beneficiaries only

[PDF] When and Why to Modify (PDF)

When and Why to Modify B illing modifiers were created to provide additional Report when you issue a voluntary ABN for a service Medicare never covers because it is statutorily providing a service Sep/Oct 2019 AUDIOLOGY TODAY 67

[PDF] DME Modifiers - CGS Medicare

16 mar 2017 · Advanced Beneficiary Notice of Noncoverage (ABN) Modifiers A list of DMEPOS modifiers is available on the PDAD Website at:

[PDF] Advance Beneficiary Notice of Noncoverage (ABN)

12 WHAT IF I FAIL TO ISSUE A MANDATORY ABN OR ISSUE A DEFECTIVE ABN? 13 WHAT CLAIM REPORTING MODIFIERS DO I USE?

[PDF] Is Your Organization Ready for AUC Implementation? Melody W

Indicates newly qualified PLEs as of June 30, 2019 6 https://www cms gov/ Table 1 HCPCS Modifiers for AUC Program HCPCS (ABN) is required? 32 32

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Is Your Organization Ready for AUC Implementation?

Melody W. Mulaik, MSHS, CRA, RCC, RCC

IR, CPC, FAHRA

Agenda

•AUC/CDS Background •Current Knowns and Unknowns/Questions •Approaching the Challenge -Bridging the Gap •Next Steps 2

Appropriate Use Criteria

Introduced in PAMA

•CT •MR •Nuclear Medicine -including PET

Utilization of Appropriate Use Criteria

(AUC) for advanced diagnostic studies

Appropriate Use Criteria

CMS can only approve the AUC that are

developed or endorsed by provider led entities (PLEs). •Must be evidence based •Listing is on CMS's website Once a PLE is qualified" all of the AUC developed or endorsed by that PLE are considered to be specified

AUC" for the purposes of the requirements.

Appropriate Use Criteria

Coronary artery

disease (suspected or diagnosed)

Suspected

pulmonary embolismHeadache (traumatic and non-traumatic)

Hip painLow back pain

Cervical or neck

pain

Shoulder pain (to

include suspected rotator cuff)

Cancer of the lung

(primary or metastatic, suspected or diagnosed)

8 Priority

Clinical

Areas

Qualified PLEs as of June 2019

American College of Cardiology FoundationAmerican College of RadiologyBanner University Medical Group-Tucson University of ArizonaCDI Quality InstituteCedars-Sinai Health SystemHigh Value Practice Academic AllianceIntermountain HealthcareJohns Hopkins University School of Medicine*Massachusetts General Hospital, Department of RadiologyMedical Guidelines InstituteMemorial Sloan Kettering Cancer CenterNational Comprehensive Cancer NetworkSage Evidence-based Medicine & Practice InstituteSociety for Nuclear Medicine and Molecular ImagingSynergetic Professional Guidelines Institute*University of California Medical CampusesUniversity of Pennsylvania Health SystemUniversity of Texas MD Anderson Cancer CenterUniversity of Utah HealthUniversity of Washington School of MedicineVirginia Mason Medical CenterWeill Cornell Medicine Physicians Organization

* Indicates newly qualified PLEs as of June 30, 2019 6 https://www.cms.gov/Medi care/Quality-Initiatives-

Patient-Assessment-

Instruments/Appropriate-

Use-Criteria-Program/PLE

Appropriate Use Criteria

•Ordering physician must access AUC through a Clinical Decision

Support Mechanism (CDSM)

•CDSM is an electronic portal -Module in an EHR -Web-based system

•CDSM will pull information about the patient from the EHR and/or the ordering physician will enter the information and immediate feedback will be provided re: appropriateness of exam

77Copyright Coding Strategies Inc. 2019

Mechanisms

https://www.cms.gov/Medicare/Q uality-Initiatives-Patient-

Assessment-

Instruments/Appropriate-Use-

Criteria

-Program/CDSM

Appropriate Use Criteria

Requirement is that AUC must

be consulted

Does not apply to inpatient,

certain emergency studies or to ordering physicians who qualify for a hardship exception •There are no hardships for furnishing professionals •CAHs are exempt 9

Radiologists will not be exempt

Ordering professionals must

communicate the results of the consultation to the imaging provider •Facility & Radiologist

Appropriate Use Criteria

Eventually outliers

will be identified

CMS will require prior

authorization for any advanced imaging studies ordered by outlier physicians 10

Implementation Timeline

Original implementation was January 1, 2017

CDS delayed in 2016-2018 Final Rules

New implementation date of January 1, 2020

-testing period of 1 year •Mandatory implementation date of 1/1/21

Voluntary reporting period of 7/2018 -12/2019

Implementation

2020 is a testing year

Medicare will pay regardless of whether or

not AUC recommends the study

Beginning January 1, 2021 payment will be

denied if the furnishing professionals' claims lack the required AUC information 12

New Reporting Requirements

•1 G-code required on the claim per mechanism •Modifiers to be assigned at the CPT code level indicating adherence to the utilized AUC •Adhered, Not Adhered, Not applicable

Required beginning 1/1/2020

•Facility -how to add modifiers •Radiologists -how to get the information

Many operational concerns with these requirements

Table 1 HCPCS Modifiers for AUC Program

HCPCS MODIFIERDESCRIPTION

Ordering professional is not required to consult a clinical decision support mechanism due toservice 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 except

ionof insufficient internet access MC

Ordering professional is not required to consult a clinical decision support mechanism due to the significant hardship except

ionof 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 except

ionof extreme and uncontrollable circumstances ME

The order for this service

adheresto the 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

Unknownif ordering professional consulted a clinical decision support mechanism for this service, related information was not providedto the

furnishing professional or provider

Emergent

Hardship

G Code Req'd

Modifiers

Table 2 G-codes for AUC Program

G-CodesDESCRIPTION

G1000 Clinical Decision Support Mechanism Applied Pathways, as defined by the Medicare

Appropriate Use Criteria Program

G1001 Clinical Decision Support MechanismeviCore, as defined by the Medicare Appropriate Use

Criteria Program

G1002 Clinical Decision Support MechanismMedCurrent, as defined by the Medicare Appropriate

Use Criteria Program

G1003 Clinical Decision Support MechanismMedicalis, 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 Medicarequotesdbs_dbs4.pdfusesText_8

[PDF] [PDF] Is Your Organization Ready for AUC Implementation? Melody W

[PDF] Medicare Advance Written Notices of Noncoverage - CMS

[PDF] Items Submitted With a GZ Modifier - CMS Manual System

[PDF] Modifiers GA, GX, GY, and GZ - Moda Health

[PDF] When and Why to Modify (PDF)

[PDF] DME Modifiers - CGS Medicare

[PDF] Advance Beneficiary Notice of Noncoverage (ABN)

[PDF] Is Your Organization Ready for AUC Implementation? Melody W

Melody W. Mulaik, MSHS, CRA, RCC, RCC

IR, CPC, FAHRA

Agenda

Appropriate Use Criteria

Introduced in PAMA

Utilization of Appropriate Use Criteria

Appropriate Use Criteria

CMS can only approve the AUC that are

AUC" for the purposes of the requirements.

Appropriate Use Criteria

Coronary artery

Suspected

Hip painLow back pain

Cervical or neck

Shoulder pain (to

Cancer of the lung

8 Priority

Clinical

Qualified PLEs as of June 2019

Patient-Assessment-

Instruments/Appropriate-

Use-Criteria-Program/PLE

Appropriate Use Criteria

Support Mechanism (CDSM)

77Copyright Coding Strategies Inc. 2019

Mechanisms

Assessment-

Instruments/Appropriate-Use-

Criteria

Appropriate Use Criteria

Requirement is that AUC must

Does not apply to inpatient,

Radiologists will not be exempt

Ordering professionals must

Appropriate Use Criteria

Eventually outliers

CMS will require prior

Implementation Timeline

Original implementation was January 1, 2017

CDS delayed in 2016-2018 Final Rules

New implementation date of January 1, 2020

Voluntary reporting period of 7/2018 -12/2019

Implementation

2020 is a testing year

Medicare will pay regardless of whether or

Beginning January 1, 2021 payment will be

New Reporting Requirements

Required beginning 1/1/2020

Many operational concerns with these requirements

Table 1 HCPCS Modifiers for AUC Program

HCPCS MODIFIERDESCRIPTION

The order for this service

The order for this service

The order for this service

Emergent

Hardship

G Code Req'd

Modifiers

Table 2 G-codes for AUC Program

G-CodesDESCRIPTION

Appropriate Use Criteria Program

Criteria Program

Use Criteria Program

Criteria Program

Medicare Appropriate Use Criteria Program

Medicare Appropriate Use Criteria Program