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The Appropriate Use Criteria 2021 Deadline: Asked and Answered

Author: Doreen DeGroff

While coronavirus waivers include some exceptions around promoting interoperability, no changes have been announced to date for the Appropriate Use Criteria requirement. The January 2021 deadline impacts reimbursement of high-value diagnostic imaging tests.  As sites progress toward AUC implementation and/or testing, there are still areas that lack clarity regarding compliance.

Below is a review of some of the common questions from facilities as they review the progress of their AUC implementation, including questions asked during a recent MUSE (MEDITECH Users Software Exchange) webcast.

Is there any indication that the Centers for Medicare Services (CMS) will postpone the 1/1/21 go-live date? 

According to the CMS website for the AUC Program, there is no mention of a delay in the January 1, 2021 go-live date. CereCore regulatory and reporting consultants have also not heard anything contrary to this.

The furnishing facility enters the modifier and the G code, yet the ordering provider is the party that receives the penalty.  Why is it that the ordering provider is penalized when there are situations they do not control such as the furnishing facility failing to add to the order?

The program guidelines and processes were set by the CMS through multiple comment periods after the Protecting Access to Medicare Act (PAMA) was first signed into law in 2014. For both the facility and the ordering provider to ensure they are meeting the criteria and will not be unfairly penalized, there should be communication and feedback loops built into the program process. This is also an excellent way to improve business processes and working relationships between the providers and the supporting facilities.

What is the best method to get referring/ordering providers who are not on our EHR system to ensure the consult information/score is on the order? Would communication regarding a deadline to accept orders without the consult information be a good approach?  

 Reaching out to referring (ordering) providers at any and every opportunity is a good way to support processes around correct documentation of future orders for these tests.  We encourage facilities to foster a solid partnership with these providers through idea sharing around the most efficient methods for managing this process. This could include sending letters, hosting lunch-and-learn, or virtual events that align your provider community around these initiatives. This is also a great way to capture the different CDSM vendors that may be utilized by these providers and build strategies for integration.

When is it expected that MEDITECH will have the workflow set up for Patient Accounting to receive the G code and modifier info to populate on claims?

MEDITECH developers have committed to a June Service Release for these changes: Magic SR35, C/S 5.67 PP 38, Expanse SR17, 6.15 SR53, and 6.08 SR42. If you do not have these service release updates on your schedules, please reach out to your MEDITECH specialists to be sure to be on the list, or reach out to CereCore for support.

Do you foresee hospitals implementing AUC consultation for inpatients? How do they handle observation patients?

Currently, AUC Consultation is only required for outpatients. Observation patients do meet the criteria and advance imaging tests ordered during the observation stay would require the consultation be completed during the ordering process.

What about orders for Emergency Department (ED) where orders prescribed by ED physicians are to be performed after the patient is discharged from the ED?

The consultation would need to be completed during the ordering process by the ED provider for tests ordered as part of the ED discharge process that falls under the AUC Criteria.

What should the Radiology Tech do if they have to change an order?

The initial consultation should suffice for orders changed due to incorrect laterality or contrast allergies, based on current information. The CMS has yet to clarify the expectation when changes may be required for other reasons, such as the provider ordering the wrong test. The current interpretation of the guidance is that a new consultation would need to be completed by the ordering provider.

Can Radiologists consult to change the order?  

No. CMS has defined that this process is completed by the ordering provider or an individual performing the consultation and order on the provider’s behalf. The Radiology staff would not meet this definition.

They further stipulated that the individual must have sufficient clinical knowledge to interact with the clinical decision support mechanism and then communicate that with the ordering professional. CMS clearly stated they expect that when someone other than the ordering provider completes this consultation and the result does not adhere to appropriate use criteria the information will be communicated back to the physician so that they could review it and ideally order a more appropriate test.

We’ve been live since the end of December and are now auditing for AUC. Can you talk about the percentage of non-compliance before action is taken against the provider or their orders?

There currently is no published guidance that explains at what point CMS would define a provider or test as non-adherent. Currently, the expectation is that the data will be assessed and sometime around 2023, the CMS will identify providers and tests that must follow the prior approval process.

Will there be a MEDITECH report where we can visualize the compliance rate of ordering providers?

There currently are no standard MEDITECH reports for AUC, however, CereCore has developed some Appropriate Use reporting options that include the ability to report by:

  • By procedure
  • By Provider
  • By Patient Type
  • By CDSM vendor
  • Orders w/o proper G-codes &/or modifier
  • Edited Orders
  • General totals, by status
  • Denials

 For additional information on Appropriate Use Criteria preparedness, click here.

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