### Related CR ####
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Appropriate Use Criteria for Advanced Diagnostic Imaging:
CY 2024 Update
Related CR Release Date: February 15, 2024
Effective Date: January 1, 2024
Implementation Date: January 3, 2025
MLN Matters Number: MM13485
Related Change Request (CR) Number: CR 13485
Related CR Transmittal Number: R12508OTN
Related CR Title: Appropriate Use Criteria for Advanced Diagnostic Imaging Policy Update in
the Calendar Year 2024 Physician Fee Schedule Final Rule
Affected Providers
•
Physicians
• Providers
• Suppliers
• Other Medicare providers billing Medicare Administrative Contractors (MACs) for
advanced diagnostic imaging services they provide to Medicare patients
Action Needed
Make sure your billing staff knows about:
• Rescinding of Appropriate Use Criteria (AUC) Program regulations
• Pausing the AUC Program for Advanced Diagnostic Imaging for reevaluation
• Elimination of AUC consultation information on Medicare Fee-for-Service (FFS) claims
Background
CR 13485 advis
es MACs of policy updates for the AUC Program for Advanced Diagnostic
Imaging resulting from changes specified in the CY 2024 Physician Fee Schedule (PFS) final
rule (88 FR 78818).
Section 218 of the Protecting Access to Medicare Act of 2014 (PAMA) established the Medicare
AUC for Advanced Diagnostic Imaging Program to increase the appropriateness of advanced
diagnostic imaging. Examples of advanced diagnostic imaging services include:
• Computed tomography
•
Positron emission tomography
• Nuclear medicine
• Magnetic resonance imaging
MLN Matters: MM13485 Related CR 13485
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Since 2015, CMS has worked to implement the statutory requirements in notice and comment
rulemaking and the Program has operated in the educational and operations testing period on
January 1, 2020, during which there were no payment penalties.
We created a number of HCPCS G codes to identify Clinical Decision Support Mechanisms and
modifiers to help implement the AUC Program. These G codes include G1000 ─ G1024 and
modifiers include MA ─ MH and QQ.
The AUC Program, as authorized in PAMA, required practitioners that order advanced
diagnostic imaging services to consult AUC using an electronic Clinical Decision Support
Mechanism (CDSM) tool when ordering these imaging services. Practitioners that provide the
imaging services reported the AUC consultation information obtained by the ordering
practitioner on the claims for the imaging services.
We finalized in the CY 2024 PFS final rule a pause to the AUC Program for reevaluation. We
also rescinded the current AUC Program regulations at 42 CFR 414.94 and reserved this
section of the regulations for future use. As described in the CY 2024 PFS final rule, we’ve
exhausted all reasonable options for fully operationalizing the AUC Program consistent with the
statutory provisions directing us to require real-time claims-based reporting to collect information
on AUC consultation as a condition of payment and identify imaging patterns for advanced
diagnostic imaging services to ultimately inform outlier identification and prior authorization.
We aren’t specifying a time frame for the start of programmatic and operational efforts. We’ll
continue efforts to identify a workable approach and will propose to adopt any such approach
through subsequent rulemaking, including implementing any amendments Congress might
make to the AUC Program statutory provisions.
Effective January 1, 2024, providers and suppliers should no longer include AUC consultation
information on Medicare FFS claims. However, claims containing AUC-related codes with dates
of service in 2023 and 2024 will continue to process.
Also, we’ll no longer qualify provider-led entities (PLEs) or CDSMs and have removed this
information from the AUC website. The claims processing instructions and guidance for the
previous voluntary period and educational and operations testing period will be removed, but
archived versions will continue to be available at CMS Transmittals
.
Consistent with the AUC Program pause and reevaluation authorized in the CY 2024 PFS final
rule, we’re instructing MACs and our shared system maintainers (SSMs) to:
• Remove and archive systems edits related to the AUC Program
• Process any advanced imaging claims that erroneously include AUC Program
G codes G1000 ─ G1024 or modifiers MA ─ MH and QQ
• Not reject or return claims to providers because of such erroneous attachment through
CY 2024
Our plan is to end the above described HCPCS G codes and modifiers, effective December 31,
2024, to assist in claims processing and data analysis.
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We’re instructing the MACs and SSMs to not reject or return advanced diagnostic imaging
claims to providers with dates of service from January 1, 2024 ─ December 31, 2024 simply
because an AUC Program G code or modifiers are submitted along with the advanced
diagnostic imaging HCPCS procedure code. MACs and SSMs will continue to process
advanced diagnostic imaging claims as usual through CY 2024 to allow time for provider
education and for providers to update their own processes and systems.
CR 13485 supersedes all prior CRs and other MAC and SSM instructions related to the AUC
Program.
More Information
We issued CR 13485 to your MAC as the official instruction for this change. Attachment 1 to this
CR details the affected codes and modifiers and includes descriptors for codes G1000 ─
G1024.
For more information, find your MAC’s website. Also view the
CMS Appropriate Use Criteria
Program website.
Document History
Date of Change
Description
February 21, 2024
Initial article released.
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