Jan. 1 MACs to Accept Appropriate Use Claims Modifiers

The Centers for Medicare & Medicaid Services (CMS) recently announced that Medicare Administrative Contractors (MAC) should begin, effective Jan. 1, 2020, accepting the Healthcare Common Procedure Coding System (HCPCS) modifiers related to Appropriate Use Criteria on Medicare fee-for-service claims for advanced diagnostic imaging services.

Protecting Access to Medicare Act of 2014 established a program to increase the rate of appropriate advanced diagnostic imaging services provided to Medicare beneficiaries. Examples of these services include:

  • Computed tomography.
  • Positron emission tomography.
  • Nuclear medicine.
  • Magnetic resonance imaging.​​

Upon full implementation in 2021, the program will require clinicians ordering an advanced image service for a Medicare beneficiary to consult an interactive electronic tool to determine whether the order adheres to the criteria and append to claims information related to the consultation. During 2020, Medicare will continue to pay claims that do not include the consultation information. Applicable settings include:

  • Physician offices.
  • Hospital outpatient departments, including emergency departments.
  • Ambulatory surgical centers.
  • Independent diagnostic testing facilities.

Applicable payment systems include the Medicare physician fee schedule, the hospital outpatient prospective payment system (PPS) and the ambulatory surgical center PPS.