Protecting Access to Medicare Act (PAMA) Keeping Informed: Appropriate Use Criteria (AUC)

PAMA established a new program to raise the number of appropriate advanced diagnostic imaging services provided to Medicare beneficiaries. This program requires the ordering professional to consult a qualified Clinical Decision Support Mechanism (CDSM) at the time advanced imaging services are ordered for a Medicare beneficiary. CDSMs are the electronic portals where ordering professionals can access the appropriate use criteria (AUC). CDSMs will provide the ordering professional with a determination of whether or not the order adheres to AUC or if no AUC is applicable. Additional information regarding qualified CDSMs, qualified Provider Led Entities (PLEs) and access to AUC can be found at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/index.html

In the 2018 PFS final rule, published Fall 2017, CMS announced the voluntary program will commence on July 1, 2018 for services furnished on or after that date. Ordering professionals may choose to consult qualified CDSMs and the furnishing professionals may choose to report limited consultation information on their Medicare claims. Modifier QQ was established to report the ordering professional consulted a qualified CDSM and this information was provided to the furnishing professional. Modifier QQ can be appended on the same claim line as any CPT code that falls within the code range as outlined by CMS if furnished in an appropriate setting.  It can be reported on both facility and professional claims.  The specific codes identified for MRIs, CTs, SPECT and Nuclear Medicine can be found in MLN Matters Number: MM10481 https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10481.pdf

The full program is expected to begin January 1, 2020. The ordering professional will be required to consult with a qualified CDSM.  The furnishing professional must append the appropriate modifier to the service line when submitting a Medicare claim for payment. During the voluntary period, MACs have been instructed to pay claims regardless of the presence of the QQ modifier.