ED Coding and Reimbursement Alert

You could also earn a 5 percent bonus for successful APM participation.

The MACRA proposed rule goes beyond MIPS to also discuss alternative payment methods (APMs) and requirements becoming a qualified or an "advanced" APM. Pay special attention to this advice because if you successfully participate in a qualified APM, thereby becoming a qualified APM participant (QP), you are both exempt from MIPS reporting and could be eligible for a lump sum incentive payment equal to 5 percent of your prior year's Part B payments beginning in 2019, Granovsky says.

Not All Bundled Payment Models Are Considered APMs Under MACRA

According to CMS, whether a bundled payment model is considered an APM depends on the model design rather than the provider's performance. Only a few bundled payment programs qualify as APMs under those criteria, including the Comprehensive Primary Care Plus model, Medicare Shared Savings Program tracks 1, 2 and 3, and the Next Generation ACO model, Clinicians in these APMs would be able to participate as a single entity in the MIPS program and be scored as one participant in all four performance categories, Granovsky adds.

What is an Advanced APM under MACRA?

The proposed rule lists criteria for an APM to be deemed eligible as an alternative payment model of an advanced APM:

• Requires participants to bear financial risk
• Bases payments on quality measures that are comparable to MIPS
• Requires its participants to use certified EHR technology (CEHRT)
• Provides for payment for covered professional services based on quality measures comparable to measures under the quality performance category under MIPS either by

     (a) requiring its participating Advanced APM Entities to bear financial risk for monetary losses that are in excess of a nominal amount, preamble, or
     (b) being a Medical Home Model

Track Both Percentage of Payments and Percentage of Patients

For an APM participant to qualify for the bonus, the percentage of Medicare payments or percentage of patients coming from APMs must increase. The percentage of payments coming from an advanced APM is proposed to increase from 25 percent in 2019 and 2020 to 50 percent in 2012 and 2022 and further increase to 75 percent in 2023 and beyond. The percentage of patients is proposed to have less dramatic increases, from 20 percent in 2019 and 220, to 35 percent in 2021 and 2022 to 50 percent in 22023 and beyond, Granovsky says.

The 8P Modifier May be Less Available in 2017

As CMS has long promised, the quality reporting program continues to shift away from pay for reporting into pay for performance. The new proposed rule on merit-based incentive payment system (MIPS) reporting indicates that CMS is placing stronger focus on a provider's performance based on actual care provided rather than just reporting as in the past.

Of Note: CMS has tipped its hand that they are looking to decrease the ability of providers to use the 8P (Performance measure reporting modifier - action not performed, reason not otherwise specified) modifier. Medicare expressed concern that a MIPS eligible provider might not be providing the actual required action but reporting the MIPS eligible quality result saying in the proposed rule, "We have eliminated some measures for which the reporting MIPS eligible clinician may not actually be providing the care, but are just reporting another MIPS eligible clinician's performance result."

Warning: MIPS generally has fewer measures and objectives for quality reporting than PQRS, for example the most commonly reported PQRS measure 54 (EKG for non-traumatic chest pain), could be removed in 2017 according to the proposed rule. Frequent use of the 8P modifier caused CMS to reevaluate its availability, Granovsky explains.