Advanced Diagnostic Imaging - Use of QQ Modifier

Advanced Diagnostic Imaging – Modifier QQ

This impacts physicians and facilities that bill Part B services for advanced diagnostic imaging to their Medicare Beneficiaries. The new item in this process is the reporting of the Healthcare Common Procedure Coding System (HCPCS) modifier QQ on the claim line for an advanced diagnostic imaging service that is paid for by CMS.

In 2014 the Protecting Access to Medicare Act (PAMA) implemented a new program that was geared towards increasing the rate of appropriate Advanced Diagnostic Imaging for the Medicare beneficiaries. The services that are included in this program are as follows:

• CT Scans

• PPET Scans

• Nuclear Medicine

• MRI

The goal was once a qualified practitioner ordered a service listed above, the practitioner was required to consult a Clinical Decision Support Mechanism (CDSM). The process would guide the individual practitioner through the electronic portal so they could access the Appropriate Use Criteria (AUC). While utilizing this system, the provider could use the CDSM to determine if the test ordered would or would not meet the AUC guidelines.

An appropriate setting for these tests to be performed are:

• Physician offices

• Hospital Outpatient Departments

• Emergency Departments

• ASCs

The payment models include the Physician Fee Schedule and the Hospital Outpatient Prospective Payment System (OPPS), and the Ambulatory Surgical Center payment model.

This program is slated to have a complete roll-out by January 2020. At that point, a consultation with a qualified CDSM will be required and the results of the consultation will need to be attached to the claim. The information needed is the NPI of the ordering physician and the identification of which CDSM that was consulted. As in the past, if there are extenuating circumstances where the provider cannot access the system due to a significant hardship or it is an emergent situation there may be exceptions made.

By placing the modifier QQ on the claim, starting in July 2018, that will identify the claim as having the following:

•         The ordering healthcare professional consulted a Qualified Decision Support Mechanism

•         The related data was provided to the healthcare professional

•         The services were provided in a qualified setting

•         The services were paid for through an approved payment model

Ultimately, this process will ensure that only tests that are medically necessary, meeting the CDSM criteria, will be approved and paid for, eliminating the ordering of tests that may not be needed as they do not meet the CDSM criteria.

Reference

Medicare Learning Network. (2018). Appropriate use criteria for advanced diagnostic imaging -voluntary participation and reporting period – claims processing requirements – HCPCS modifier QQ. Retrieved from https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10481.pdf