Appropriate Use Criteria

After upgrading to Professional EHR 19.4, Radiology Decision Support can be activated to prompt providers at the point of care, allowing them to review the appropriateness of the diagnostic imaging test they have ordered based on the diagnosis. But how does this really work? How do you communicate this information with the Practice Management system so the correct information is on the claim?

Setup is required in EHR and PM for billing. In EHR and PM, you must:

  1. Add or activate the G code. G1004 reflects that a Clinical Decision Support Mechanism National Decision Support Company, as defined by the Medicare Appropriate Use Criteria Program, aka, CDSM NDSC, CareSelect, was used to determine the appropriateness of the diagnostic test.

  2. Add the following modifiers

  •        ME – The order adheres to the criteria.

  •       MF – The order does not adhere to the criteria.

  •       MG – The order does not have any criteria in the CDSM.

  •       MA – An emergency medical condition.

  •       MB – Insufficient internet access.

  •        MC – EHR or CDSM vendor issues.

  •       MD – Extreme or uncontrollable circumstances.

  •       MH – It is unknown if a consultation was performed.

Once set up is complete, providers or clinical staff on the provider’s behalf document in the EHR.

  1. Place the diagnosis and diagnostic procedure in Assessment and Plan.

  2. Attach the correct modifier to the diagnostic procedure.

  3. Include the G code in the encounter if modifier ME, MF, or MG are attached.

  4. Remember that the diagnostic imaging code and the G code must be billable to cross the interface.

eHealth has a workflow for this and can assist you with setup if needed. Please let us know if you need assistance to create an efficient workflow for your practice.

Schedule your upgrade – remember, you must be on 19.4 or higher before December 2020 to continue to ePrescribe. The upgrade schedule at Allscripts is filling up so you need to go ahead and schedule.

This upgrade requires planning. It can be quite a shock to users because of the different colors and icons – a completely different user interface. We have several dates on the calendar for Implementing Pro EHR 19.4. Have an upgrade party in the conference room and make the most of this class!