HCPCS Modifier MC

Description
An ordering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of electronic health record or clinical decision support mechanism vendor issues.                                                                                                                 

Guidelines/Instructions

• This modifier is effective for services provided on or after January 1, 2020
• Providers should submit this modifier with the appropriate advanced diagnostic imaging service. Examples of advanced imaging services include computed tomography, positron emission tomography, nuclear medicine, and magnetic resonance imaging. 
• The ordering professional will be required to consult a qualified clinical decision support mechanism (CDSM). This is an interactive, electronic tool for use by clinicians that communicates appropriate use criteria (AUC) and assists in making the most appropriate treatment decision for the patient. 
• The CDSM will provide the ordering professional with a determination of whether that order adheres to AUC, does not adhere to AUC, or if there is no AUC applicable in the CDSM consulted.  Exceptions to consulting CDSMs include:
  • The ordering professional having a significant hardship exception;
  • Situations in which the patient has an emergency medical condition; or
  • An applicable imaging service ordered for an inpatient and for which payment is made under Part A
• During this phase of the program, claims will not be denied for failing to include or for misreporting AUC related information, however inclusion is encouraged

Full program implementation is expected January 1, 2021

Resources

• Change Request (CR) 11268 (PDF)
• CMS MM11268 (PDF)