The Centers for Medicare & Medicaid Services (CMS) initiated the educational and operations testing phase of the Appropriate Use Criteria (AUC) program. During this period, Medicare Administrative Contractors (MACs) began accepting AUC-related modifiers and HCPCS G-Codes on claims for advanced diagnostic imaging services provided to Medicare Part B patients.
Understanding AUC Program Requirements
Under the AUC program, ordering professionals must consult a qualified Clinical Decision Support Mechanism (CDSM) before ordering advanced imaging services for Medicare patients. This requirement applies to services provided in specific settings and must be documented for claims submission.
Applicable Advanced Imaging Services
- Magnetic Resonance Imaging (MRI)
- Computed Tomography (CT)
- Single-Photon Emission Computed Tomography (CPT 76390)
- Nuclear Medicine
Who Must Comply with AUC Requirements?
The AUC program applies to imaging services provided in the following settings:
- Physician offices
- Hospital outpatient departments (including emergency departments)
- Ambulatory surgical centers (ASCs)
- Independent diagnostic testing facilities
It also applies to payments made under these payment systems:
- Physician Fee Schedule (PFS)
- Outpatient Prospective Payment System (OPPS)
- Ambulatory Surgical Center Payment System (ASC PS)
Exceptions to CDSM Requirements
The CDSM consultation requirement does not apply if:
- The ordering professional has a significant hardship (e.g., insufficient internet access, vendor issues, or uncontrollable circumstances).
- The patient has an emergency medical condition requiring immediate care.
- The patient is an inpatient, and the service will be billed under Medicare Part A.
Reporting Requirements: HCPCS Level II Modifiers
To comply with the AUC program, claims must include an appropriate HCPCS Level II modifier indicating adherence or an exception to the requirement:
Modifiers Indicating Exceptions:
- MA – Emergency medical condition; consultation not required.
- MB – Significant hardship due to insufficient internet access.
- MC – Significant hardship due to electronic health record (EHR) or CDSM vendor issues.
- MD – Significant hardship due to extreme and uncontrollable circumstances.
Modifiers Indicating Adherence to AUC:
- ME – Service adheres to AUC guidelines.
- MF – Service does not adhere to AUC guidelines.
- MG – No applicable AUC guidelines exist for this service.
- MH – Unknown whether a CDSM was consulted.
- QQ – CDSM was consulted, and data was provided (effective July 1, 2018).
Categories of HCPCS G-Codes
Here are some common categories and examples of G-codes:
1. Preventive & Screening Services
These codes are used for preventive care covered by Medicare.
- G0101 – Cervical or vaginal cancer screening; pelvic and clinical breast exam
- G0102 – Prostate cancer screening; digital rectal exam
- G0328 – Fecal occult blood test, immunoassay, colorectal cancer screening
2. Telehealth & Virtual Services
G-codes are widely used in Medicare-covered telehealth services.
- G2010 – Remote evaluation of recorded video/images submitted by the patient
- G2012 – Brief communication technology-based service (virtual check-in)
- G2252 – Extended virtual check-in (11-20 minutes)
3. Chronic Care & Care Coordination
These codes support chronic disease management and care coordination.
- G0506 – Comprehensive assessment for Chronic Care Management (CCM)
- G0511 – Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) CCM
- G0512 – Behavioral health integration services in RHCs/FQHCs
4. Therapy & Rehabilitation Services
These codes are used for physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP).
- G0283 – Electrical stimulation therapy
- G0515 – Cognitive skills development therapy
- G0129 – Therapeutic behavioral services
5. Quality Reporting & MIPS Measures
G-codes play a key role in Medicare quality reporting programs, such as MIPS (Merit-Based Incentive Payment System).
- G8482 – Smoking cessation intervention
- G8427 – Documentation of current medications in medical record
- G8856 – Depression screening
The Importance of HCPCS G-Codes for Allzone Medical Coding Company
HCPCS G-Codes are crucial for Allzone Medical Coding Company because they play a vital role in accurate medical billing, compliance, and reimbursement, especially for Medicare and other government-funded healthcare programs. Here’s why they matter:
1. Essential for Medicare Reimbursement
- HCPCS G-Codes are primarily used by Medicare to report and reimburse specific procedures, services, and quality measures that do not have an equivalent CPT code.
- Ensuring accurate usage of these codes helps healthcare providers receive proper reimbursement and avoid claim denials.
2. Quality Reporting & Value-Based Care
- Many G-Codes are used in MIPS (Merit-Based Incentive Payment System) and other value-based payment models, impacting provider performance scores.
- Proper coding of these measures ensures compliance with CMS (Centers for Medicare & Medicaid Services) regulations.
3. Compliance & Audit Readiness
- Using the correct HCPCS G-Codes helps prevent billing errors, audits, and penalties.
- Allzone’s expertise in coding ensures that providers remain compliant with federal guidelines.
4. Billing for Non-Physician Services
- G-Codes cover a range of services like telehealth, care coordination, and chronic care management, which are essential for modern healthcare billing.
5. Competitive Advantage for Allzone
- Allzone’s deep understanding of HCPCS coding updates positions it as a reliable partner for healthcare providers seeking accurate and efficient coding services.
- This expertise helps in optimizing revenue cycles and ensuring maximum reimbursement.