Starting January 1st 2020, documentation concerning the consultation of a Clinical Decision Support Mechanism (CDSM) is necessary for Medicare claims for advanced imaging tests (MRI, CT, PET and Nuclear Medicine).

January 1, 2020 begins a year long “operations and testing” period where there is no risk to payment if documentation is incorrect or missing. However, the testing period will be crucial to ironing out any kinks in the process before the program is fully implemented January 1, 2021 – the date when CMS will begin not paying claims lacking required documentation. 

Communication between key players in the process is critical to compliance with the Appropriate Use Criteria/Clinical Decision Support (AUC/CDS) program, with Radiology practices bridging the gap between everyone involved.

Working with referring providers, facilities, EHR and CDSM vendors on how AUC documentation flows from point to point will be critical to beginning to test compliance with the program.

AUC/CDS documentation ultimately gets transmitted to CMS on Medicare claims using modifiers and G-codes.   At a high-level, the modifiers and G-codes provide the following information:

A CDSM was consulted and the result was:

o  Appropriate – indicated by using the ME modifier

o  Not appropriate – indicated by using the MF modifier

o The service does not have appropriate use criteria – indicated by using the MG modifier

These three results require a corresponding G-Code which shows which CDSM was consulted. Each qualified CDSM has their own unique G-code.

A CDSM was not consulted due to a hardship

o  A suspected or confirmed medical emergency – indicated by using the MA modifier

o  Vendor issues with a CDSM or EHR – indicated by using the MC modifier

o  insufficient internet access – indicated by using the MB modifier

o  Extreme or uncontrollable circumstances – indicated by using the MD modifier

Unknown if the ordering professional consulted a clinical decision support mechanism

o  Indicated by using the MH modifier

With several parties all playing a part in the AUC/CDS program, it’s important to start having conversations on how the process will work for your group and getting questions answered now.

CLICK HERE for guidance on what questions to ask and more resources on the AUC/CDS program.


Kayley Jaquet

Manager of Regulatory Affairs