General Question for the Week of July 12, 2021

Question:

Regarding the Appropriate Use Criteria (AUC) program, CMS recently stated “Currently, the program is set to be fully implemented on January 1, 2022, which means AUC consultations with qualified CDSMs are required to occur along with reporting of consultation information on the furnishing professional and furnishing facility claim for the advanced diagnostic imaging service. Claims that fail to append this information will not be paid.” Our hospital images are read by an outsourced radiology group. Will the hospital still receive payment for the technical portion if AUC requirements are not met? Will the radiologist’s claim be completely denied?

Answer:

When the program becomes fully operational, if an AUC consult was not performed by the referring physician, neither the hospital nor the interpreting physician will be paid (assuming billed to OPPS for the hospital, and the Medicare Physician Fee Schedule for the physician). More information can be found at:
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program. Both the hospital claim and the interpreting physician claim will need to have the appropriate modifier and G code on the claim. If either claim does not have an appropriate modifier and G code, that claim will be denied.