By Elizabeth W. Woodcock, MBA, FACMPE, CPC MGMA Reimburseme… · 2016-11-10 · 2014-2.0% - - -...

By Elizabeth W. Woodcock, MBA, FACMPE, CPC

2016©

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Elizabeth W. Woodcock, MBA, FACMPE, CPCSpeaker, Author, Trainerwww.elizabethwoodcock.com MBA, Wharton School of Business, University of Pennsylvania BA, Duke University Fellow, American College of Medical Practice Executives Certified Professional Coder Author, 16 textbooks and more than 500 Articles Founder and Principal, Woodcock & Associates Former Consultant, Medical Group Management Association; Group Practice Services Administrator, University of Virginia Health Services Foundation; Former Senior Associate, Health Care Advisory Board

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Medicare 2017 ICD10 Meaningful Use Penalties Quality Payment Program

Merit-based Incentive Payment System

Conclusion

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CMS Final Rule

November 2, 2016

Publication Date: November 16, 2016

http://bit.ly/2fz0P3M

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2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Law

Actual

Exception - 2014Q1 had a 0.5% rate increase

0.50%

(0.26%)

0.24%

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Average cuts based on claims processed under the taxonomy code associated with the specialty; represents RVU changes only. Includes physician specialties only. All other specialties 0% impact.

Review Your Appendix

Allergy/Immunology 1% Ophthalmology -2%Family Medicine 1% Urology -2%General Practice 1% Gastroenterology -1%Geriatrics 1% Interventional Radiology -1% Internal Medicine 1% Neurosurgery -1%

Oral/Maxillofacial Surgery -1%Otolaryngology -1%Pathology -1%Radiology -1%

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Effective for services furnished beginning

January 1, 2017… [Medicare] reduces by

20 percent the payment amounts…for the

technical component (TC) (including the

TC portion of a global service) of imaging

services that are X-rays taken using film.

The modifier FX, would be required on claims for the technical component of the X-ray service, including when the service is billed globally,

Modifier FX

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G0502: Initial psychiatric collaborative care management, first 70 minutes in the first calendar

month of behavioral health care manager activities…

G0503: Subsequent psychiatric collaborative care management, first 60 minutes in a

subsequent month of behavioral health care manager activities…

G0504: Initial or subsequent psychiatric collaborative care management, each additional 30

minutes in a calendar month of behavioral health care manager activities…

Behavioral Health

Note: CPT codes are a registered trademark of the

American Medical Association (AMA). Please

review the complete definition in your CPT®

Manual, and any applicable guidance from the

Centers for Medicare & Medicaid Services if billing

a Medicare-only “G” code.

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99490 Chronic Care Management Services

“Services are provided when medical and/or psychosocial

needs of the patient require establishing, implementing,

revising, or monitoring the care plan. Patients who receive

chronic care management services have two or more

chronic conditions or episodic health conditions that are

expected to last at least 12 months, or until the death of

the patient, and place the patient at significant risk of

death, acute exacerbation/decompensation, or functional

decline.”

$40.82Starting with January 1, 2015 Dates of Service

Reimbursement based on current “Georgia - 1020201” reimbursement for Medicare 2016. Locality 1020299 (“Rest of Georgia”) is $38.91. Non-

facility.

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G0506: Comprehensive assessment of and care planning by the

physician or other qualified health care professional for patients requiring

chronic care management services, including assessment during the

provision of a face-to-face service (billed separately from monthly care

management services) (Add-on code, list separately in addition to primary

service).

99490

99487 Complex chronic care w/o pt vsit99489 Complex chronic care addl 30 min

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Review Your Appendix

99490 – Highlight of Changes

• Creation of structured clinical summary record not

required.

• Separate written patient consent not required; sufficient

to document acceptance of services in medical record.

• 24/7 access equates to contact with health care

professional; access to electronic care plan not required.

• Care plan can be shared with other practitioners via fax.

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CPT code 99358 (Prolonged evaluation and

management service before and/or after direct patient care,

first hour); and

CPT code 99359 (Prolonged evaluation and

management service before and/or after direct patient care,

each additional 30 minutes (List separately in addition to

code for prolonged service).

Non-Face-to-

Face Services

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TelehealthESRD-Related Services

Advanced Care PlanningCritical Care Telehealth Consults

New Place of Service Code 02

Under ScrutinyZero-Day Global Services billed

with Modifier -25

Global Period@270 CPT Codes

Surgeons in Groups of 10+9 States; Not MS

Informal ReviewPQRS/VBPM informal review streamlined for participating

physicians

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TelehealthESRD-Related ServicesAdvanced Care PlanningCritical Care Telehealth Consults

New Place of Service Code 02


with Modifier -25




physicians

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New Place of Service Code


with Modifier -25




physicians

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with Modifier -25

Global Period@270 CPT CodesSurgeons in Groups of 10+9 States; Not MS


physicians

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with Modifier -25




physicians

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Commercial

Government

Self 100%

<5%

50%

5%

35%

60%

32%

Source: Woodcock & Associates analysis of professional fee receivables, 2016.

Patient Financial

Responsibility

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Don’t want to go paperless? Not a problem. If you would like to continue to receive paper statements in the mail, you’ll be required to pay an annual fee of $20 which is due today. Please let us know! Yes, I want the environmentally friendly option; instead of paper, please send my

statements to: ___________________________________ . No, I would like to continue receiving paper statements, and will pay the annual fee of

$20. Patient Signature/Name/Date

Dear Patient:In an effort to be more environmentally friendly, XYZ Medical Practice is now offering eStatements. Choosing this option allows you to receive your statements electronically, sent to you via email. You no longer have to hassle with paper statements. In addition to being environmentally friendly, eStatements are convenient and secure. As soon as your statement is ready, you will be notified via email. The email will provide a link to a secure website where you can not only view your statement, but also choose one of several payment options.

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Was Over

October 1,

2016

ICD-10

2017 Updates (Oct 1, 2016-Sept 30, 2017) Posted

http://go.cms.gov/28ZiPxA

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…any continuous 90-

day period between

January 1, 2016 and

December 31, 2016.

http://bit.ly/2fz0P3M

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Year eRx PQRS EHR (MU) VBPM+ Total

2012 -1.0% - - - -1.0%

2013 -1.5% - - - -3.5%

2014 -2.0% - - - -4.0%

2015 - -1.5% -1.0% -1.0% -5.5%

2016 - -2.0% -2.0% -2.0% -8.0%

2017 - -2.0% -3.0% -4.0% -9.0%

2018 - -2.0% -3.0% -4.0% -9.0%+Value-Based Payment Modifier phases in the payment adjustments based on the size of the practice.

Remember… 2018 is being determined by your participation in 2016!!

Penalties for Not Participating (in the

Government’s Programs) are Piling Up

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CO237 = Legislative Penalty

N699 = PQRS

N700 = EHR Incentive Program

N701 = Value-Based Payment Modifier

http://go.cms.gov/2e1Zv5Z

Medicare Remittance

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1. Advanced

Alternative Payment

Model (APM)

Participant

2. Everyone Else

Merit-based Incentive

Payment System

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$30,000 in Total Allowed Part B Charges

1. Allowed charges = Allowable for that particular service

99213 $200.00 $73.40CPT® Your Charge Allowed Charge*

*Reflects the current (2016) National Payment Amount for 99213; non-facility price.

This is only an estimate, but this translates into $60,000 to $90,000 in gross

charges for most medical practices.

Payment

$??

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“…Beneficiaries enrolled in Medicare Advantage plans that receive their Part B

services through their Medicare Advantage plan will not be included in allowed

charges billed under Medicare Part B for determining the low-volume threshold.”

- CMS

2. Part B = Traditional Medicare. It does not include

Medicare Advantage.

$30,000 in Total Allowed Part B Charges

• First Year Medicare Participant^…

• Perform Services for <100 Medicare patients

• Not enrolled in Medicare

^Per CMS, “a professional who first becomes a Medicare-enrolled eligible clinician within the PECOS.”

CMS will perform a quarterly check.

32.5%

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“[We] intend to provide a NPI level lookup feature prior to or shortly after

the start of the performance period that will allow clinicians to determine if they do not exceed the low-volume threshold and are therefore excluded

from MIPS.”-CMS

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October 14, 2016

List of Advanced APMs

Source: CMS. https://qpp.cms.gov/docs/QPP_Advanced_APMs_in_2017.pdf

“These APMs are

scheduled to be

implemented in 2017 or

2018 but have design

parameters that have not

yet been finalized. We

will update this list … to

reflect changes as they

are finalized.” 5 to 8%New ACO Track One Model 2018

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2-Year

2019

Deadline

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Option Result

Report all required elements for 90 consecutive days

Bonus

Report >1 quality measure, >1 improvement activity and all ACI measures

“Small” bonus

1 quality measure; 1 improvement activity OR all ACI measures

No payment increase; no penalty

Advanced APM Automatic 5% increase

“Pick Your Pace” 2017

If you do nothing, you will be penalized 4% on all of your Medicare reimbursement.

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Potential for 3x adjustment for

“exceptional performance”

+4%

-4%

+5%

-5%

+7%

-7%

+9%

-9%

Adjusted Medicare Part B Payment to Clinician

[ based on a MIPS Composite Performance Score ]

2019 2020 2021 2022 onward

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1

Quality

2

Cost

3

Advancing Care Information

4

Improvement Activities

Eliminated in 2017

Composite Performance

Score

Advancing Care Information = New Name for “Meaningful Use”

All measures can be viewed at https://qpp.cms.gov/

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Basically Replicates the Current

Programs from a Reporting Perspective

“MACRA requires us to measure performance, not

reporting.” - CMSSource: CMS, Final Rule (10/14/16)

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Performance = Comparison to

measure-specific benchmarks

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QualityMeasure

100 Patients

80 Patients

80% 90%Measure-Specific

https://qpp.cms.gov/

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• Medicare 2017

• New Payer in the Market

• ICD10

• Meaningful Use

• Penalties

• Quality Payment Program

• Merit-based Incentive Payment System

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Question & Answer Session

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Exempt from MIPS? Low-Volume Threshold Determination Period

“…Define the low-volume threshold determination period to mean a 24 month assessment period, which includes a two-segment

analysis of claims data during an initial 12-month period prior to the performance period followed by another 12-month period

during the performance period. The initial 12-month segment of the low-volume threshold determination period would span from the

last 4 months of a calendar year 2 years prior to the performance period followed by the first 8 months of the next calendar year

and include a 60-day claims run out, which will allow us to inform eligible clinicians and groups of their low-volume status during the

month (December) prior to the start of the performance period. To conduct an analysis of the claims data regarding Medicare Part B

allowed charges billed prior to the performance period, we are establishing an initial segment of the low-volume threshold

determination period consisting of 12 months.

12 months of data starting from September 1, 2015 to August 31, 2016, with a 60 day claims run out.

Material in this Appendix from the Centers for Medicare &

Medicaid Services (CMS) extracted from October 14, 2016 Final

Rule, noting that it will be published in an upcoming Federal

Register that will have a future date, unless otherwise specified.

https://qpp.cms.gov/docs/CMS-5517-FC.pdf

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• Physician

• Physician assistant

• Nurse practitioner

• Clinical nurse specialist

• Certified registered nurse anesthetist

Eligible Clinicians

• Can instead report as a group• There will be an “election process.” “…If a group is submitting information

collectively, then it must be measured collectively for all four MIPS performance

categories: quality, cost, improvement activities, and advancing care information.” - CMS

• “Virtual groups” can be formed, but not until 2018

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Eligible Clinicians

“While we have multiple identifiers for participation and performance, we are finalizing

the use of a single identifier, TIN/NPI, for applying the MIPS payment adjustment,

regardless of how the MIPS eligible clinician is assessed…Each unique TIN/NPI

combination will be considered a different MIPS eligible clinician, and MIPS

performance will be assessed separately for each TIN under which an individual bills.”

“[Others]… may voluntarily report on measures and activities under MIPS, but will not be

subject to the MIPS payment adjustment.”

Payment Adjustments will not be Applied to FQHC or RHC All-Inclusive Rates, so

Participation is not Expected, but it is Voluntary

Source: CMS, Final Rule (10/14/16)TIN = Tax Identification Number

NPI = National Provider Identifier

MIPS = Merit-based Incentive Payment System

FQHC = Federally Qualified Health Center

RHC = Rural Health Clinic

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Basically Replicates PQRS from a Reporting Perspective

Per CMS, “The CPT codes that have historically been available under the PQRS program will be made available for the MIPS as part of the detailed measure

specifications which will be posted prior to the performance period at QualityPaymentProgram.cms.gov.”

Almost Exactly the Same Measures (271), as well as Reporting Options

CMS Web Interface for Groups

Qualified Clinical Data Registry (QCDR)*

Qualified Registry

Electronic Health Record

Claims

Accountable Care Organization~

*More information: https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/pqrs/qualified-clinical-data-registry-reporting.html

At least 50% of patients that meet

the measure’s denominator criteria,

regardless of the payer

Same, but only Medicare Part B

Sample provided by CMS; 248

Medicare beneficiaries

No separate reporting; via ACO

~“Official” ACO, recognized as able to successfully submit data to CMS (e.g., Medicare Shared Savings)

PQRS = Physician Quality Reporting System

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Base Score

50 Points

[ Required Measures* ]

*Failure to report any of these five elements successfully results in a “zero” base score, which automatically translates into a “zero” performance

score for this category.

^MIPS-eligible clinicians who write fewer than 100 permissible prescriptions in a performance period may elect to report a null value.

Perform Security Risk Assessment

(Y/N)

ePrescribe^

Send Summary of Care

Request/Accept Summary of Care

Provide Patient Access

In 2017, can

use 2014 or

2015 Edition

CEHRT; must

be 2015

Edition

certified in

2018.

This table reflects the 2015 Edition of CEHRT (Certified EHR Technology). If using 2014 Edition, see the “Transition” objectives

applicable for 2014 Edition users on the next page; these are slightly different.

*Required for Base Score, noting that your performance also contributes to your supplemental performance score.

Per CMS, “The performance score…is based on a MIPS eligible clinician’s performance rate for each measure reported for the

performance score (calculated using the numerator/denominator).” If your ratio is 90 out of 100 patients, for example, you’ll get 90% of

10 points, which is 9 points.

^Recommended, as “Yes” achieves the full 10 points.

Category Maximum # of Points

Provide Patient Access* 10

Patient-Specific Education 10

View, Download or Transmit 10

Secure Messaging 10

Patient-Generated Health Data 10

Send a Summary of Care* 10

Require/Accept Summary of Care* 10

Clinical Information Reconciliation 10

Immunization Registry^ 10

Bonus: (Any) Public Health/Clinical Data Registry^ 5

Bonus: Report your improvement activities using CEHRT^

10

Need 50

Points Here

to Maximize

Your

Performance

Score

(100)

155 Total

2015 Edition of CEHRT

This table reflects the 2014 Edition of CEHRT.

*Required for Base Score, noting that your performance also contributes to your supplemental performance score.

Per CMS, “The performance score…is based on a MIPS eligible clinician’s performance rate for each measure reported for the

performance score (calculated using the numerator/denominator).” If your ratio is 90 out of 100 patients, for example, you’ll get 90% of

10 points, which is 9 points.

^Recommended, as “Yes” achieves the full 10 points.

Category Maximum # of Points

Provide Patient Access* 20

Patient-Specific Education 10

View, Download or Transmit 10

Secure Messaging 10

Health Information Exchange* 20

Medication Reconciliation 10

Immunization Registry^ 10

Bonus: (Any) Public Health/Clinical Data Registry^ 5

Bonus: Report your improvement activities using CEHRT^

10

Need 50

Points to

Maximize

Your

Performance

Score

MIPS Category

Advancing Care Information

2014 Edition of CEHRT

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Regularly assess the patient experience of care through

surveys, advisory councils and/or other mechanisms.

Seeing new and follow-up Medicaid patients in a

timely manner, including individuals dually eligible for

Medicaid and Medicare (HIGH).

Timely communication of test results defined as timely

identification of abnormal test results with timely

follow-up.

Performance of regular practices that include providing

specialist reports back to the referring…clinician or

group to close the referral loop or where the referring

…clinician or group initiates regular inquiries to

specialist for specialist reports which could be

documented or noted in the certified EHR technology.

Implementation of regular care coordination training.

Improvement Activity

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Elizabeth W. Woodcock, MBA, FACMPE, CPC

Woodcock & Associates

Speaker, Trainer, Author

Atlanta, Georgia

404.373.6195

[email protected]

www.elizabethwoodcock.com

These handouts may not be reproduced without the written consent of the speaker.

By Elizabeth W. Woodcock, MBA, FACMPE, CPC MGMA Reimburseme… · 2016-11-10 · 2014-2.0% - - -...

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