Section title: Requests for Interpretation
RFI #
2387
AUC Mandate
Description

The Protecting Access to Medicare Act of 2014 mandates that all ordering providers consult with Appropriate Use Criteria through a clinical decision support mechanism prior to ordering an advanced imaging service for a Medicare beneficiary. The law requires that three data elements be included on all advanced imaging claims: 1-NPI of ordering professional; 2-Clinical Decision Support Mechanism used; and 3-Whether the order adhered, did not adhere, or was not applicable to specified AUC. Our goal is to implement this mandate in the least burdensome way possible for all parties. We believe that the actions we are requesting will allow CMS and imaging stakeholders to efficiently communicate the required AUC data elements on each advanced imaging Medicare claim.

Response

This RFI is ONLY applicable for the version 005010X223A2 837 Institutional Technical Report Type 3 (TR3) and versions thereafter until a permanent solution is provided within a future 837I TR3 .
The 837 workgroup approves the use of Loop ID 2300 K3 segment in the Institutional 837 to support CMS Medicare requirements of reporting Ordering Provider NPI for the appropriate use criteria (AUC) program. For information about AUC see Section 218(b) of the Protecting Access to Medicare Act of 2014, which amended Title XVIII of the Social Security Act to add section 1834(q) directing CMS to establish a program to promote the use of AUC for advanced diagnostic imaging services.
When reporting the Ordering Provider NPI, the K3 will use the following values for each service line that need an Ordering Provider reported:

AUC represents the program
LX represents the service line followed by the service line number reported in LX01
DK represents the Ordering Provider followed by the Ordering Provider NPI

If an Ordering Provider NPI is the same for multiple service lines, each service line must be reported separately in the K3. The K3 segment supports 80 characters, which may allow up to four Ordering Provider NPI iterations in a single K3. Additional K3 segments can be sent as needed but each one must begin with the value of AUC as shown above below.

K3 Examples:
Reporting 1 Ordering Provider NPI
K3*AUCLX1DK1111111111~

Reporting 5 Ordering Provider NPIs
K3*AUCLX1DK1111111111LX11DK9999999999LX22DK1111111111LX433DK2222222222~
K3*AUCLX444DK4444444444~

RFI Recommendation

See the Centers for Medicare & Medicaid Services (CMS) website Appropriate Use Criteria Program page for all other related instructions and information:  https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Ins…

DOCUMENT ID
005010X223A1