New Medicare Physician Payment Program Doesn’t Delay ICD-10-CM Implementation!

Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure the accuracy of the information. However, HMP Communications and the authors do not represent, guarantee, or warranty that the coding, coverage, and payment information is error-free and/or that payment will be received. The ultimate responsibility for verifying information accuracy lies with the reader.

In 2014 the patch to the Medicare Physician Fee Schedule (MPFS) payment system, commonly known as the sustainable growth rate (SGR), delayed the implementation of the ICD-10-CM diagnosis coding system just six months before it was scheduled to “go live.” Shortly after the ICD-10 implementation delay was announced, the Centers for Medicare & Medicaid Services (CMS) rescheduled the ICD-10 implementation date to Oct. 1, 2015. In April of this year, Congress surprised everyone by repealing the SGR payment system, but this time the new law did not include language to delay ICD-10. Therefore, Oct. 1 remains as the deadline for implementation of the new diagnosis coding system.

On April 16, President Obama signed a new law that permanently reformed MPFS. The new law is called the Medicare Access and CHIP [Children’s Health Insurance Program] Reauthorization Act of 2015 (MACRA). The new Medicare physician payment system established by MACRA is called the Merit-Based Incentive Payment System (MIPS). Following are some highlights of the planned transition from the current volume-based MPFS to the value-based MIPS. (For all details related to MACRA, click here).

• The MPFS payment rates that were in place from Jan. 1, 2015-March 31, 2015 are extended through June 30, 2015. • Chronic-care management services furnished by a physician, physician assistant (PA), nurse practitioner (NP), clinical nurse specialist, or certified nurse-midwife on or after Jan. 1, 2015, must be paid as long as they do not duplicate other Medicare payment. • On July 1, 2015, MPFS allowable rates will be increased by 0.5%. • MPFS allowable rates will increase 0.5% each year from 2016 through 2019. • There will not be any MPFS allowable rate increases from 2020 through 2025. • After 2025, there will be two separate MPFS allowable rate conversion factors: 1. The qualifying alternative payment model (APM) and 2. The nonqualifying APM. • The MIPS will begin on Jan. 1, 2019. — Physicians, PAs, NPs, clinical nurse specialists, certified registered nurse anesthetists, and group practices will receive bonuses based on quality of care rather than increases based on the number of services and procedures performed. NOTE: After 2021, MIPS may also be extended to “other eligible professionals (EPs)” as designated by CMS. Some of the “other EPs” might be: physical and occupational therapists, qualified speech-language pathologists, audiologists, certified nurse-midwives, clinical social workers, clinical psychologists, and registered dieticians/nutrition professionals. — The three existing quality programs: electronic health record (EHR); Meaningful Use Incentive Program; value-based modifier (VBM), and Physician Quality Reporting System (PQRS) will be consolidated into one quality incentive program. The following four performance categories and their assigned “weights” will transition from fee-for-service reimbursement to value-based reimbursement:

1. Quality Measures, which will use: • existing PQRS measures and • qualified clinical data registry (QCDR) measures. The good news is that beginning in 2016, group practices and individual EPs may report quality measures through qualified clinical data registries. NOTE: The public will be involved in the development of quality measures for MIPS and APMs. MACRA made available $15 million per year for fiscal years 2015-19 for quality measure development activities. By Jan. 1, 2016, CMS must post a draft plan for the development of quality measures. Comments must be accepted through March 31, 2016, and an operational plan must be posted by May 1, 2016. Beginning May 1, 2017, CMS must provide annual progress reports on quality measure development activities. Quality Measures MIPS Weight = 30% (Exception: 50% in 2019 and 45% in 2020).

2. Resource-Use Measures, which will use existing VBM methodology. NOTE: MACRA directs CMS to account for the cost of Part D drugs when feasible and applicable. Resource-Use MIPS Weight = 30% (Exception: 10% in 2019 and 15% in 2020).

3. Clinical Practice Improvement Activities Measures, to minimally include: • expanded access (eg, same-day appointments); • population management (eg, participation in a QCDR); • care coordination (eg, use of remote monitoring or telehealth); • beneficiary engagement (eg, use of shared decision-making); • patient safety and practice assessment (eg, use of surgical checklists); • alternative payment model (APM) participation. Clinical Practice Improvement Activity MIPS Weight = 15%

4. Meaningful Use of EHR Measures, which will use existing Meaningful Use program requirements. Meaningful Use of EHR MIPS Weight = 25% (Exception: as low as 15% if EHR adoption reaches 75%, with compensating adjustments to other category weights).

__________________________________________________________ 
RELATED CONTENT
Business Briefs Archive
Wound Clinic Business
 __________________________________________________________

EPs will receive a composite performance score of 0-100 based on their performance in each of the four performance categories, which will be compared with a performance threshold. This score will then translate into one of four payment adjustments for EPs: 1. Negative Adjustments: (4% in 2019, 5% in 2020, 7% in 2021, and 9% in 2022 and beyond) will be imposed on EPs whose composite performance score is between zero and one-fourth of the performance threshold. 2. Zero Adjustments: will be imposed on EPs whose composite performance score is at threshold. 3. Positive Adjustments: will be awarded to EPs whose composite performance score is above the threshold. The amount of the payment adjustment will vary based on the amount of negative payment adjustments because budget neutrality must be maintained. 4. Additional Incentive Payment Adjustments: will be awarded to EPs who have exceptional performance. Better performers will receive larger payments — $500 million will be distributed annually on a linear basis for years 2019 through 2024. The additional payment adjustment for an EP may not exceed 10%. NOTE: Beginning July 1, 2017, EPs must be provided with timely (eg, quarterly) confidential feedback pertaining to their performance on quality and resource-use measures. Feedback may also be provided regarding the EP’s performance on clinical practice improvement and EHR Meaningful Use measures. Beginning July 1, 2018, EPs must be provided with feedback pertaining to services received by their patients from other suppliers and providers. In years 2020 through 2025, MIPS will not increase the MPFS allowable rates. Instead, EPs will be eligible for either of the two following:

1. Quality programs bonuses: (Poor performers will incur payment reductions.) The quality measures must be developed in consultation with the public and must focus on: • outcome measures (including patient-reported outcomes and functional- status measures); • patient-experience measures; • care-coordination measures; and • appropriate-use-of-services measures (including measures of overuse). QCDRs are allowed to assist in quality-improvement activities, under certain circumstances.

2. Bonuses for their participation in an APM that focuses on coordinating care, improving quality, and reducing costs. NOTE: There will be two routes of APM participation. See Table 1 for an overview of the two routes of APM participation and the APM bonus schedule. Medicare APMs may include: • a model tested by the Center for Medicare and Medicaid Innovation; • an accountable care organization under the Medicare Shared Savings Program; • a demonstration under the Health Care Quality Demonstration Program; • a demonstration required by federal law. As depicted in Table 1, for 2025 and beyond, Medicare payments for EPs will be based on two separate annual updates: • EPs who participate in qualified APMs will be eligible for a 0.75% “qualifying APM conversion factor.” • All other EPs will be eligible for a 0.25% “nonqualifying APM conversion factor.”

Beginning July 1, 2016, MACRA also expands the availability of Medicare data: • Qualified entities (QEs) may use Medicare data to conduct nonpublic analyses and to sell such analyses to authorized users for nonpublic use (eg, to assist providers to develop and participate in quality- and patient care-improvement activities). QEs may also receive standardized extracts of Medicaid and CHIP claims data. • QCDRs may request Medicare claims data and, as CMS determines appropriate, Medicaid and CHIP claims data to link with clinical outcomes data and for analyses in support of quality-improvement and patient-safety activities.

APMs and qualified APM participants may furnish telehealth services that are not currently paid by Medicare. By April 2017, MACRA requires Government Accountability Office studies regarding potential use of telehealth and remote patient monitoring for Medicare beneficiaries.

SUMMARY

MACRA ends the EPs’ uncertainty about their Medicare payment system, which has undergone 17 patches for more than 10 years. MIPS allows EPs to focus on providing high-quality patient care at lower costs. More information pertaining to number of services furnished, submitted charges, and Medicare payments will be publicly available about physician services provided to Medicare beneficiaries. In addition, Dec. 31, 2018, is the target date for achieving widespread exchange of health information through interoperable certified EHR technology. MACRA includes many other Medicare payment provisions, some of which still require instructions from CMS. Stay tuned as CMS releases more details pertaining to all of the MACRA Act provisions and to each phase of MIPS implementation!

Kathleen D. Schaum, MS, is president and founder of Kathleen D. Schaum & Associates Inc., Lake Worth, FL; and director, medical products, reimbursement, biotherapeutics at Smith & Nephew.