CMS is establishing a program under the Protecting Access to Medicare Act of 2014 to address the appropriate use of advanced imaging for Medicare beneficiaries. Beginning January 1, 2023, or end of public health emergency, providers or delegated clinical staff will be required to consult a Clinical Decision Support Mechanism (CDSM) for determination of appropriate ordering. All physicians and other practitioners (physician assistant, nurse practitioner, clinical nurse specialist) are required to consult a CDSM at the time of ordering.
Which services will be required for review under a CDSM?
- Computed tomography
- Positron emission tomography
- Nuclear medicine
- Magnetic resonance imaging
See a list of Common Procedural Terminology (CPT) codes here.
In which settings is appropriate use criteria followed?
- Physician office
- Hospital outpatient department
- Emergency department
- Ambulatory surgery center
- Independent imaging facility
What does this mean for billing and claims processing?
Providers billing to a Medicare Administrative Contractor (MAC) will be required to submit modifiers with the imaging code on professional and technical claims. In addition, a G code for the consulted CDSM will be submitted on the claim. A list of CDSMs and the appropriate G code can be found here.
Appropriate modifiers must be submitted along with the advanced imaging CPT code to identify adhering to criteria or appropriate exception Modifier QQ must be used to indicate the CDSM was consulted and outcome relayed to a health professional. Modifiers MA-MH are used when indicating the services met an exception to the criteria at the time of ordering.
If claims are submitted without all necessary elements, the organization may experience denials. If a denial is received, the patient cannot be liable for services rendered. In addition, if providers are determined to have outlier ordering practices, prior authorization may be required for advanced imaging services.
For more information, reach out to your BKD Trusted Advisor™ or submit the Contact Us form below.