Appropriate Use Criteria – Delayed but Not Gone

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Catherine Short speaks with Melody Mulaik, President of Revenue Cycle Coding Strategies, a dynamic company that works with physician practices, healthcare systems, billing companies and other industry stakeholders to provide auditing, education and other collaborative consulting solutions to meet their coding and compliance needs. First Healthcare Compliance is a proud partner of Revenue Cycle Coding Strategies and our clients have enjoyed many webinars and previous podcasts by this team of experts. Melody joins us to address a current hot topic, “AUC – Delayed but not Gone.” 2022 was scheduled to be the official implementation date for AUC/CDS implementation but the 2022 Proposed Rule threw everyone a little curve ball. While a delay has occurred, it does not change the direction of the program or the need to prepare and test.  As providers continue to either prepare their own practices or bridge the gap with imaging facilities, it is important that everyone be on the same page throughout the CMS implementation and remaining testing period.

 

AI TRANSCRIPT – misspellings may occur

 

  • 23:11

SUMMARY KEYWORDS

providers, ordering, cms, compliance, auc, patient, implementation, radiologists, edi, organizations, implement, consultation, hospital, question, coding, medicare, system, physician, modifiers, talking

SPEAKERS

Catherine Short, Melody W. Mulaik

 

Catherine Short  00:01

Welcome! and, let’s “1st Talk Compliance”. I’m Catherine Short, Partnership Marketing Manager at First Healthcare Compliance. Thanks for tuning in.

 

This show is brought to you by First Healthcare Compliance as part of our commitment to provide high quality complimentary educational resources.  We help create confidence among compliance professionals throughout the United States.  Please show your support by taking a moment to provide a review on Google, Facebook or iTunes.  You can also follow us on Instagram, Twitter and subscribe to our YouTube channel.

 

Catherine Short  00:37

Today, we are speaking with speaking with Melody Mulaik, President of Revenue Cycle Coding Strategies, a dynamic company that works with physician practices, healthcare systems, billing companies and other industry stakeholders to provide auditing, education and other collaborative consulting solutions to meet their coding and compliance needs such as “AUC – Delayed but not Gone.” First Healthcare Compliance is a proud partner of Revenue Cycle Coding Strategies and our clients have enjoyed many webinars and previous podcasts by this team of experts.

 

2022 was scheduled to be the official implementation date for AUC/CDS implementation but the 2022 Proposed Rule threw everyone a little curve ball. While a delay might occur, it does not change the direction of the program or the need to prepare and test.  As providers continue to either prepare their own practices or bridge the gap with imaging facilities, it is important that everyone be on the same page throughout the CMS implementation and remaining testing period.

 

Working through the charge capture processes and identifying where gaps currently exist will ensure that plans can be quickly implemented to address these concerns and ensure that the potential new Jan. 1, 2023 implementation date is successful and that no one’s revenue is disrupted. Melody will share implementation stories to assist listeners with their final preparations.

 

Catherine Short  02:10

Before we begin, I would like to mention at First Healthcare Compliance we strive to serve as a trusted to resource for compliance professionals and celebrate their hard work and dedication with our Compliance Super Ninja recognition.  Here we are spotlighting Super Ninja, Sharon Miller, Administrator at Gulf Coast Dermatopathology Laboratory. Sharon says “Patient care is paramount and by creating a culture of caring, compassion and respect we have succeeded in all we do. We try to promote a family atmosphere which in turn translates ultimately to patient care.” Congratulations Sharon!  Our team is honored to have the privilege of working with you.

 

Catherine Short  02:52

Melody, it is such a pleasure to speak with you again on 1st Talk Compliance!  Thank you for being here!

 

Melody W. Mulaik  02:58

Thank you, Catherine. It’s always a pleasure.

 

Catherine Short  03:01

Yes, it is a pleasure. I remember we had a great time speaking in New Orleans a while ago now prior to the pandemic. And it seems like a lifetime ago now.

 

Melody W. Mulaik  03:10

It definitely does. It’s amazing how quickly time has flown for sure.

 

Catherine Short  03:14

I know, I know. Well, today we’re going to talk about AUC and the delay and what’s going to be happening. So as we begin, can you first give us a brief background as to what AUC is and why and for who it exists?

 

Melody W. Mulaik  03:32

Sure, absolutely. So as you see appropriate use criteria consultation requirement got introduced back in 2014. So it’s been a long time ago, in the Protecting Access to Medicare Act, and it was originally scheduled to go into effect January one to 2017. And the program is requiring ordering providers that are ordering any advanced imaging modality studies of CT Mr. PET scans, nuclear medicine scans, it’s actually consult this official clinical criteria that’s been developed by providers to ensure that the exams that they’re ordering are the most clinically appropriate for patients.

 

Catherine Short  04:10

Okay, great. So, what do you think then are the biggest challenges for ordering providers? For AUC?

 

Melody W. Mulaik  04:18

I think for ordering providers, the biggest challenge is is doing performing the consultation in the in the most efficient way in the most non disruptive way. I mean, the reality is no one’s in love with this program. I mean, we just have to kind of call call it what it is right? I mean ordering providers as a whole especially when you get into the specialist you know, this is what they do. I mean talking to a neurosurgeon about ordering an MRI of the brain or a CT of the brain or talking to an orthopedist about ordering a joint study those kinds of things. You know for them is a little like why am I reading required to do this I you know, when you get into some of the other areas of general practitioners Internal Medicine. Finally practice where maybe they don’t have as much exposure to some of the all of the imaging modalities for different areas. Some might say there’s some other opportunities related to that. But I do think that’s one of the big challenges with it. So you’ve got a system, you got a process that no one’s really fond of. So how do you implement it in a way that’s as efficient as possible and least disruptive utilizing your system so that you’re meeting the intent of the requirement, but not having to put in a lot of extra work? Because we already know when you think about taking care of patients, people talk in terms now of how many clicks? Is it in electronic medical record? And how you know how much you staring at the screen versus talking to the patient. And so implementing this so that it’s not adding a lot of additional time? And tracking that is important. I mean, the studies that I’ve shown, say that if you implement it correctly, you should only be adding seconds to the process, not minutes to the process. So aim for the seconds, not the minutes.

 

Catherine Short  05:56

Then what about for radiologists? What do you think are the biggest challenges for radiologists? For AUC?

 

Melody W. Mulaik  06:04

Well, I think for radiologists, you know, and really, the challenge for them is they’re put in this position where they’re really having to be the police officers in some ways, right? I mean, if somebody doesn’t do the consultation, they’re the ones having to say, Well, gee, I can’t do this scheduled outpatient for your procedure, you know, for your patient until you do this. And so radiology gets put in this position of enforcement in a lot of ways. And I think that’s a difficult position to be in. So again, how do you do it in a way that’s efficient for the ordering provider, but also, you’re not losing your own revenue, because the radiologist and an imaging center or hospital, whoever’s doing that technical component, are the ones who have revenue at risk, if the ordering provider doesn’t do the consultation, so they’re the ones that have to put that that hurdle up, so to speak, to say, you know, gee, I’m sorry, Dr. Smith, you didn’t do this consultation, I can’t do this study for this patient. And so if especially for physician, a radiologist is hospital based, they’re now also counting on the hospital to get that data for them from the ordering provider, and have it get to their staff or to their billing company, in a way so they’re not losing revenue. So I think the radiologists do have a lot of risk, because they’re a step away from it, if they’re in a hospital based practice. So I think that that’s one of their big challenges for sure.

 

Catherine Short  07:21

Okay, and then what about in the emergency department? Do you think that ED orders are ever going to be excluded?

 

Melody W. Mulaik  07:30

You know, it’s an interesting question. I think the short answer that a lot of people would say is we hope so. But right now, I mean, CMS has made it very clear, including the final rule this year for 2022. That said, the EDI as a whole is not exempt. I mean, CMS has been focused on orders in the EDI for a long time. So that’s one of the reasons they want to address it. But I think the challenge is that the penalty of this is that ordering providers that don’t quote, order the correct exams, and become the outliers are going to be put on 100% prior authorization? Well, that doesn’t really mesh with an ad physician, right? You don’t do prior authorization in the emergency department. And so how do you? How do you find that balance? And I think it really speaks to an even broader issue around, you know, insurance companies are now controlling, when you go to the ED versus not they’ve increased their co pays for it, and even have some payers that say, if it’s determined that you didn’t have an emergency, then we’re not going to pay for the visit. And this is kind of CMS his way of trying to control some of that. And I don’t know that it’s necessarily the best way. And and I think we’re going to continue to see it evolve. And it’s one of those things that as we officially finally get into that penalty phase, and they start collecting data, then maybe CMS can use the data that they receive as a way to help Congress change the law or change the implementation of the policy to actually achieve something that’s meaningful, but as it’s written right now, I would argue it’s probably not as meaningful in the EDI setting as maybe they intended it to be.

 

Catherine Short  09:01

What do you think the probability or possibility is that Congress will ever intervene? Possibly cancel the program? What are your thoughts on that?

 

Melody W. Mulaik  09:10

You know, that’s always a big question. Because it goes through these cycles, where you’ll get some of the professional societies will band together and they’ll go to Congress, and they’ll pitch it to be the big issue. And I think it really just depends on what’s the hot topic. And right now, some of the cuts that have come to reimbursement for some of the specialists is really the hot topic. And that’s going to take precedence over implementation of a UC. So I think as we get closer to implementation, again, it’s going to depend on what’s going on in the industry. What’s the big focus point, if there’s not a lot else being focused on we may see it pop back up, we may find that there are, you know, congressmen or women that are interested in supporting it and that it goes through but if otherwise, Washington is so unpredictable, I think it has been for a long time. You don’t know what they’re going to do. So I wouldn’t count on it. A lot of times, we’re here people say Oh, I, you know, my specialty society says it’s never going to happen. No one can say that with any confidence with it. So at this point, we just have to follow what CMS has said, it’s going to go into effect. And we just have to keep going down that direction. Because the other piece I’ll just throw in is, you know, people have spent millions and millions of dollars to implement it. So if you’ve already made everybody go through it, how do you maximize it? And then what do you do with it versus just saying, Okay, nevermind, we’re not going to do it that that wouldn’t. I don’t know that that would necessarily make everybody happy either. I’ve talked to a lot of hospitals that have said, even if CMS said, we’re not going to do it, they would still have it implemented, just because they want to make sure the right exams are ordered.

 

Catherine Short  10:42

Okay, so actually, that leads me to another question, what if a facility has a provider who refuses to comply with the ordering requirements? What do they do, then?

 

Melody W. Mulaik  10:51

That’s a good question. And that’s something a lot of organizations struggle with, because you really, you get into that clinical versus non clinical, and it’s really difficult for a non clinical not only person, but non clinical type of entity to go tell a physician what to do. And so there’s got to be ownership of this at a at a clinical leadership level. So whether that’s the Chief Medical Officer, what you know, whatever that comes out to be, they have to be bought in, and they have to be the ones that’s communicating with those ordering providers. And so clearly, whether they’re employed or not employed is going to come into play. If they’re employed providers, you’ve got a lot more of control and influence, because that’s going to come affect their contract, if they’re not employed. You know, you, you can say, basically, I’m not going to do study if it’s for scheduled outpatient. And, you know, do you risk losing their business, the rest of their business? You do, but how many studies do you want to do for free as well, I mean, the one thing when you think about this, is, you have to really look at your payer mix to it, because we’re talking about Medicare only. So if I’m in an organization where let’s say that I have a huge amount of commercial payers, and Medicare is a very small percentage, that how I approach this with my providers may be very different than if I’m running 40 50% Medicare, right. So if I’m running 40 50%, Medicare, I’m going to be doing an awful lot more education, I’m going to be really working hand in hand to implement more with systems make it easy as possible, because I can’t afford to lose any of that business. If I if I’m a very small percent Medicare, and maybe I’ve got a few physicians who were sending me a lot of those patients, and I lose that percentage of because they choose not to be compliant, that’s probably not going to hurt me as much as other scenarios. So I do think there’s not a one size fits all solution for things every organization has to determine its financial risk, its compliance risk, and be very proactive to communicate so that they minimize their losses.

 

Catherine Short  12:44

If you’re just tuning in, you’re listening to 1st Talk Compliance brought to you by First Healthcare Compliance as part of our commitment to provide high quality complimentary educational resources.  We help create confidence among compliance professionals throughout the United States.  My guest today is Melody Mulaik, President of Revenue Cycle Coding Strategies, about “AUC – Delayed but not Gone.” Please show your support by taking a few minutes to provide a review of First Healthcare Compliance on Google or Facebook.  You can also follow us on Instagram, Twitter and subscribe to our YouTube channel.

 

Catherine Short  13:22

So Melanie, what are some of the outstanding questions regarding a UC implementation that you would see the answer to in 2022?

 

Melody W. Mulaik  13:32

That’s a good question. I mean, they CMS answered a lot of questions in the 2022 final rule, but there are still a few things they have on like, for example, they indicated that instead of denying claims that they would reject them, if it didn’t contain the appropriate information, which on the surface sounds great. Okay, you’re not going to make me go through appeals. But what do you mean by what types of things? Are you going to reject? Are you saying that if it doesn’t have a modifier, and you think it should you’re going to reject it? But what if the ordering provider didn’t do the consultation, and I knew that whether they were, you know, a, an observation patient or scheduled outpatient? Is there a way for me to submit that claim? And know that I’m not going to get paid but yet still haven’t followed the process? So I think that’s one a particular concern for people is what’s going to happen in those scenarios? related to it, I think understanding what the modifiers are going to be there’s some new modifiers they’re going to give us and they haven’t communicated what those modifiers are going to be yet. So I think we’re interested in those and what are the rules around those modifiers? Also, are they going to give us a when you when you look at explanation of benefits, remittance advices that come back, there’s it’s a set code set that says so it’s standard, okay, this particular code means a denial or rejection for this, creating those and so that way we know are there going to be denial or rejection codes very specifically around a C we believe there is but we need to know what those are so that we can build All those into our systems as well. So they’ve made some, some adjustments, but it, it’s been pretty big. Yeah, for some of it, yeah, some of it, some of it has been vague, at least it’s a good next step for some of those kinds of things. But for some of them, they definitely could do more, they definitely could give us more information for sure.

 

Catherine Short  15:22

Okay, what do you think the biggest system challenges are going to be with implementation?

 

Melody W. Mulaik  15:30

You know, it’s it really, it’s, it is a system issue in a lot of ways, because we don’t want to have a lot of human intervention. But I think ensuring that all the systems are talking to each other as they should, whether it’s a ordering providers, electronic, you know, health record, talking to the hospital systems, or communicating with an imaging center. And then making sure as things are flowing through a hospital system, that the data goes to the radiology practice, as it should, I mean, I’ve heard stories where, you know, it’s it’s not giving their billing company, the modifier in the G code, it’s giving them it’s telling them the name of the system, the mechanism, but then it’s giving them quote, the score from there and the mechanism and saying, Oh, it’s a seven, or it’s an eight, well, then somebody is physically having to go through and look at that and go, Okay, well, that’s going to be an Emmy modifier, we shouldn’t have to have any human interaction with this or human intervention, rather with it, it needs to be everything that smooth fluid flows through with everything. The other piece of that is you’ve obviously got to have it resources. And just like with everything else going on IT resources can be very thin in some organizations, or maybe the hospitals going through a big, you know, system implementation for something else, or whatever the reason is, you almost have to line up those resources months in advance. And so if I’m an ordering provider, I’m going to want to get on the list sooner rather than later, if I’m the radiologist, I’m going to want to make sure that my needs are taken care of sooner rather than later. So that I’m not in a situation where all of a sudden, I’m saying, oh, I need help with this interface. And they go, Well, gee, I wish she told me three months ago, because we can address this until April of 23. So that I think that’s a very real risk for a lot of organizations.

 

Catherine Short  17:11

Okay, speaking of this score, regarding ordering patterns, how can ordering providers get their data on their score? Guarding these ordering patterns?

 

Melody W. Mulaik  17:22

You know, it depends on the system that they’re using the mechanism, the mechanisms, all should have some type of standardized reporting that are built into them, at least I would say, and if they don’t be surprised that that they were were approved as a mechanism, so should be some standard scores in there. I would also recommend, though, that organizations look at what are some other customizable reports that can be done, you know, and usually, there’s ways to take that raw data and do something with it, whether you’re pulling it out in a CV, you know, an cvs file, or CSV file and get my not confuse it with the pharmacy CSV file, and you can convert it into Excel, and you can manipulate and do a lot of things with it. But if you’re using the hospital system, they have that data. And so I would just request it, I would ask them to have data for your particular practice on a monthly basis and ask them to sort it by provider as well as by modality and they definitely can do that for you.

 

Catherine Short  18:17

Okay, and then what’s a piece of advice that you would give to both ordering providers and interpreting providers?

 

Melody W. Mulaik  18:27

I think, you know, just kind of overall advice is, is don’t assume everything will work smoothly out of the gate, because when you look at it, it seems pretty straightforward. Okay, we have a mechanism, I do a consultation that data flows through, goes through the system, and I would almost apply Murphy’s Law, right, whatever can go wrong. Well, so give yourself time to think about all the different scenarios, think about all the different places you might send your patients, do all of those scenarios work, how can I make sure that I have a way to do to take care of the patients do the orders I need to do without disrupting the patient? I think for the radiologists a little bit of the same thing, you know, what, what do I not know? And how do I partner with the hospital? Because basically a hospital practices I think your your biggest risk for radiologist imaging centers are more straightforward. Is is what do I not know? And how do I partner with the hospital it and hospital radiology department to make sure we’ve thought through all the scenarios of where we get patients from? And how are we going to get that information so that I don’t have a cash flow disruption caused by denials?

 

Catherine Short  19:32

Okay, and then what are some key areas that you think organizations should focus additional time on during this process?

 

Melody W. Mulaik  19:42

Well, the ED is definitely one. That’s a big deal from that standpoint. So EDI would be a particular area, I think observation as well just to make sure that the process flows are there so that there’s not any disruption. I would argue that scheduled outpatient should be the most straightforward those are not emergent cases, we should have time to go through that particular process. Related to that. But yeah, I think those are probably the two biggest focus areas.

 

Catherine Short  20:10

And do you think there’s still any, any other unknowns from CMS that you think need to be addressed?

 

Melody W. Mulaik  20:16

You know, I’m sure there is. But it’s one of those things that you don’t know until you get there. I will say as it continues to evolve, there’s always something that comes out every year as an organization is working through implementation, that they share in the industry that the group kind of says, Wow, we didn’t think about that. So I think it’s to be continued, There absolutely, will be, and I’m sure there’s going to be things that even as we are implementing, officially, and we get into that penalty phase in 2023, that there’s going to be things that come back that we didn’t think about either.

 

Catherine Short  20:49

And I think we have time for maybe one more question here. So do you think that are all imaging organizations? Are they offering some kind of mechanism for ordering providers to consult? Or what’s your, what do you think on that?

 

Melody W. Mulaik  21:04

That’s a good question I think the most are that I’m hearing just because they recognize that the harder you make it for an ordering provider, to do the consultation, the lessons gonna, they’re gonna send stuff to your organization. So I do think that most places are doing that, that said, there are places that are just probably going to say, hey, here’s a link to the free website, you know, go ahead and use it, and then, you know, print this off and send it to this type of thing. So, you know, I think people are really have to look at the competitive nature of where the landscape of where they’re at, and how much that’s going to impact them. And, you know, it’s a balancing act of being frugal, and making things easy for your ordering provider. I mean, personally, I recommend making as easy as possible for your ordering providers.

 

Catherine Short  21:48

Yeah, I would think so too, I would think so. I want to ask you, do you have any other advice for for our listeners, as we wrap up?

 

Melody W. Mulaik  21:58

I would just say just stay tuned, you know, as we’re going into 2022, and just, there’s going to be updates that come out, pay attention to them, listen to them. Think about the operational implications of everything. It’s not just about the the, what does CMS require, but how do we operationalize that from whatever our perspective is, to make sure we make it easy on the possible on our providers, and transparent to our patients?

 

Catherine Short  22:22

Perfect. Well, thank you so much. Thank you for coming on today. Melody, this is really, really great information and very much appreciate it. So thank you. It’s fantastic. Appreciate it.

 

Melody W. Mulaik  22:33

Thanks, Catherine. Appreciate the opportunity.

 

Catherine Short  22:35

Thank you. And thanks to our audience for tuning in to 1st Talk Compliance. You can learn more about the show on the programs page on HealthcareNOWRadio.com.

 

 

And lend your voice to the conversation on Twitter at @1sthcc or hashtag #1sttalkcompliance. You can also email me at catherineshort@1sthcc.com.  I’m Catherine Short of First Healthcare Compliance. Remember, compliance is key to achieving peace of mind

 

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