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Minnesota AUC Rules Resources

Minnesota AUC Newsletter

August 2019

We’re Back! MN AUC News Returns!

As some readers may recall, the Minnesota Department of Health (MDH) published a monthly newsletter with and on behalf of the Minnesota Administrative Uniformity Committee (AUC) for several years, when it was discontinued following changes in staffing and priorities.

We are restarting the newsletter to keep the AUC and other interested groups up to date and informed. We plan to include regular status updates about AUC’s work and activities, as well as summaries of other relevant news, tips, and updates in a brief digest format. We actively encourage your feedback and contributions. Please tell us what you think about the newsletter, any information and news that you think would be helpful to include, as well as other feedback or suggestions you think may be helpful.

National News

Are you ready for CMS’s “Appropriate Use Criteria Program”?

The following brief summary is provided following recent meetings at a number of levels of the AUC (the Operations Committee, Medical Code Technical Advisory Group (TAG), and an additional ad hoc small group) to create greater awareness of and readiness to implement the federal Centers for Medicare & Medicaid Services (CMS) “Appropriate Use Criteria Program.” Given the AUC’s focus on health care administrative transactions, please note the Program’s requirements for certain information to be included on claims submitted to Medicare in the near future.

Federal legislation enacted in 2014 to increase the rate of appropriate advanced diagnostic services provided to Medicare beneficiaries is being implemented with important deadlines for many health care providers to be met soon.

The 2014 law created a new CMS program to ensure that orders for advanced diagnostic imaging meet certain “appropriate use criteria.” Examples of advanced diagnostic imaging include: computed tomography (CT); positron emission tomography (PET); nuclear medicine; and magnetic resonance imaging.

According to CMS, “Under this program, at the time a practitioner orders an advanced diagnostic imaging service for a Medicare beneficiary, he/she, or clinical staff acting under his/her direction, will be required to consult a qualified Clinical Decision Support Mechanism (CDSM). CDSMs are electronic portals through which appropriate use criteria ... is accessed. The CDSM provides a determination of whether the order adheres to [the criteria], or if the [criteria] consulted was not applicable (e.g., no [appropriate use criteria] is available to address the patient’s clinical condition).”

CMS has also published a limited number of exceptions to the requirements to consult CDSMs, including: ordering professional having a significant hardship; the patient has an emergency medical condition; and the applicable imaging service was ordered for an inpatient and for which payment is made under Part A.

Ultimately, practitioners whose ordering patterns are considered outliers will be subject to prior authorization. A CMS notice and comment rulemaking process will be used to develop the outlier methodology before the prior authorization component begins.

CMS also reports that “Currently, the program is set to be fully implemented on January 1, 2021 which means consultations with qualified CDSMs are required to occur along with reporting of consultation information on the furnishing professional and furnishing facility claim for the advanced diagnostic imaging service. Claims that fail to append this information will not be paid. Prior to this date the program will operate in an Education and Operations Testing Period starting January 1, 2020 during which claims will not be denied for failing to include proper AUC consultation information.”

On July 26, 2019 CMS published MLN Matters Number MM11268, with a list of HCPCS modifiers to be used when reporting information on claims for the Appropriate Use Criteria Program. The modifiers are to be placed on the same line of the claim as the CPT code for the advanced diagnostic imaging service. In addition, certain modifiers will also require additional reporting of G codes to indicate which of several available CDSMs was consulted.

For more information, please see the Medicare Learning Network (MLN) Matters documents numbers ICN 909377, MM10481, and MM11268.

Comment on National “Interoperability Standards Advisory (ISA)” by September 23, 2019

The ISA includes standards and specifications for health care administrative transactions

Each year the federal Office of the National Coordinator for Health Information Technology (ONC) coordinates the identification, assessment, and public awareness of interoperability standards and implementation specifications that can be used by the healthcare industry to address specific interoperability needs including, but not limited to, interoperability for clinical, public health, and research purposes.

The result is the publication of an annual Interoperability Standards Advisory that represents ONC’s current assessment of the Health Information Technology (HIT) landscape, including standards and specifications for health care administrative transactions.

ONC recently announced that it is now soliciting public comments and suggestions to update the ISA for the 2020 version. Comments will be accepted by the ONC through September 23, 2019.

“The ISA ... plays a key role in ONC’s efforts to implement the 21st Century Cures Act. Your continued feedback is critical to ensure that the ISA includes the most up-to-date and accurate state of health IT standards across the US.”
ONC, July 23, 2019

Minnesota AUC

Minnesota Uniform Companion Guides

Minnesota Statutes, section 62J.536 requires that MDH consult with the AUC on the development and adoption into rule of Minnesota Uniform Companion Guides (MUCG). The MUCG serve as companion documents to the implementation guides adopted for health care administrative transactions pursuant to federal HIPAA regulations (45 CFR 162).

MDH reviews MUCG that have been adopted into rule for any necessary revisions and updates approximately annually with the assistance of the AUC. Below is a brief status report regarding recently completed revisions of the MN uniform companion guides, as well as reviews now underway for possible upcoming revisions.

Revised 835 MUCG to be adopted into rule August 12, 2019

A revised version of the MUCG now in force for the X12 835 transaction is scheduled to be announced as an adopted rule in the August 12, 2019 edition of the State Register. The revised version will be known as version 14.0 and will become effective as a rule 30 days after publication in the State Register. When effective, v14.0 will supersede all previous versions.

837I and 837P MUCG now under review for possible revisions/updates

MDH and the AUC’s Medical Code TAG and Claims Data Definition Technical Advisory Groups (TAGs) are currently reviewing the MUCG for claims transactions (X12 837P and 837I transactions) for any possible revisions as part of “annual maintenance” of the MUCG.

AUC Technical Advisory Groups (TAGs)

The majority of the AUC’s work, including developing recommendations to MDH regarding the Minnesota Uniform Companion Guides (MUCG) described above, as well as education, outreach, and related activities to reduce health care administrative costs, occurs in specially designated groups of subject matter experts known as Technical Advisory Groups (TAGs). All TAG meetings are open, public meetings and anyone interested is invited to attend. Most meetings are conducted virtually, via dial-in and WebEx.

Below is a brief update of recent TAG activity and related work now underway and/or recently completed.

Eligibility TAG

The TAG is in the process of drafting and revising several consensus-based “best practices” for effective use of the X12 Eligibility Inquiry and Response (270-271) transaction. As the best practices are developed and approved by the TAG they will be forwarded to the AUC Operations Committee for final review and approval to be published on the AUC website.

Explanation of Benefits (EOB)/Remittance Advice TAG

The “EOB/Remit” TAG completed its review and recommendations of revisions to the 835 MUCG earlier this spring as part of the MUCG’s annual maintenance. As noted above (see related article, page 3), the revised 835 MUCG is scheduled to be announced as an adopted rule in the Minnesota State Register on August 12, 2019.

In addition, the TAG also reviewed the X12 proposed implementation guide (IG) for the 7030 version of the 835 transaction and developed comments to submit on behalf of the AUC to X12 regarding the proposed IG.

Medical Code TAG (MCT)

The MCT is reviewing a major Appendix in the 837I and 837P MUCG with medical coding information and instructions. The MCT also recently reviewed information regarding the CMS Appropriate Use Criteria Program (see first article of this newsletter) and suggested that the information be more widely disseminated through this newsletter and other means.

Claims Data Definition (DD) TAG

The Claims DD TAG is also participating in reviews of the 837I and 837P MUCG as part of “annual maintenance” described above.

Upcoming AUC meetings/activities

Information regarding AUC meetings and activities can be found on the AUC calendar and the AUC Technical Advisory Groups (TAGs) webpage.

Other News

DHS Provider News

The Minnesota Department of Human Services (DHS) administers several publicly funded health programs (“Minnesota Health Care Programs (MHCP))” including Medical Assistance, Minnesota’s name for Medicaid. DHS is a “group purchaser” (payer) subject to Minnesota Statutes, section 62J.536 requirements for the standard, electronic exchange of certain health care administrative transactions, including requirements of the Minnesota Uniform Companion Guides (MUCG) discussed above.

DHS is also an active member and participant on the AUC, and publishes a regular electronic newsletter with news and resources for providers enrolled to serve MHCP members. Given that the DHS “MHCP provider news and updates” newsletter may be of interest to AUC members as well, all issues of this newsletter will also include a “reminder” link to the DHS newsletter webpage for easy reference. Providers may also sign up to receive the DHS newsletter directly through DHS’s free provider email lists.

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