Avoid Increased Prior Authorizations with HCPCS Modifier QQ

Posted by Robert Lynch on Mar 12, 2018 3:34:26 PM
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Effective July 1, 2018, HCPCS modifier QQ (Ordering Professional Consulted A Qualified Clinical Decision Support Mechanism For This Service And The Related Data Was Provided To The Furnishing Professional) is available for reporting. The modifier may be:

  • Used when the furnishing professional is aware of the result of the ordering professional’s consultation with a CDSM for that patient,
  • Reported on the same claim line as the CPT code for an advanced diagnostic imaging service furnished in an applicable setting and paid for under an applicable payment system, and,
  • Reported on both the facility and professional claim.

When this program is more fully implemented (expected January 1, 2020), consultation with a qualified CDSM will be required and detailed information regarding the ordering professional’s consultation must be appended to the furnishing professional’s claim. This includes the ordering practitioner’s NPI and documenting which CDSM was consulted (there are multiple qualified CDSMs available). Ultimately, this program will result in identified outlier ordering professionals being subject to prior authorization. Any increase in prior authorizations will add to a growing trend in prior authorization requirements in radiation oncology.

Background on the QQ Modifier

The Protecting Access to Medicare Act (PAMA) established a new program to increase the rate of appropriate advanced diagnostic imaging services provided to Medicare beneficiaries. Examples of such advanced imaging services include computerized tomography, positron emission tomography, nuclear medicine, and magnetic resonance imaging. Under this program, at the time a practitioner orders an advanced imaging service for a Medicare beneficiary, he/she will be required to consult a qualified Clinical Decision Support Mechanism (CDSM). CDSMs are the electronic portals through which practitioners access appropriate use criteria (AUC) during the patient workup. The CDSM will provide the ordering professional with a determination of whether the order adheres, or does not adhere, to AUC, or if there is no AUC applicable. A list of qualified CDSMs is available here.

A consultation must take place for an applicable imaging service ordered by an ordering professional that would be furnished in an applicable setting and paid under an applicable payment system. Please note that the applicable setting is where the imaging service is furnished, not the setting where the imaging service is ordered.

In the calendar year 2018 PFS final rule, CMS stated that the program would begin with a voluntary participation period. During this period, ordering professionals may choose to consult qualified CDSMs; and furnishing professionals may choose to report limited consultation information on their Medicare claims.

Contact New Bedford or your radiation oncology billing service to determine how to plan for the implementation of this new code.

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Topics: Prior Authorization

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