ED Coding and Reimbursement Alert

Look for new names for PQRS, Meaningful Use and the Value Based Modifier Programs.

The Centers for Medicare and Medicaid Services, (CMS) released its 962 page MACRA proposed rule on April 27^th. Although this proposed rule is open to comment and not final, it hints at what Medicare has in store for future ED payments.

Acting CMS Administrator Andy Slavitt announced that the meaningful use program as it has existed is effectively over and will be replaced with something better — “A new powerful program that is much easier to use, lowers-burden and that promotes connectivity and innovative technology.” But that may be in the eye of the beholder.

In the proposed rule, which will impact services as early as 2017, the current programs for quality reporting, PQRS, meaningful use and the value based modifier have been reorganized and given new names along with a complicated weighted point and scoring system, says Michael A. Granovsky, MD, FACEP, CPC, President of LogixHealth a national ED coding and billing company based in Bedford, MA.

Look For Familiar Programs With New Names in 2017

CMS proposes to replace the current incentive structures the three main quality-reporting programs of the physician quality reporting system (PQRS), meaningful use, and value-based modifier (VBM), with a single performance score based on four weighted categories for each provider or practice, says Granovsky.

The new categories are quality, advancing clinical information, cost, and clinical practice improvement activities, each with a weighting for the percentage of your total performance score.

Quality: This category replaces the current PQRS and has a year one weight of 50 percent of the total MIPS score.

In 2017 MIPS reporting allocates half of your total MIPS score to your quality measures and there is some good news. In 2016, you’re required to report nine measures across three domains; in 2017 you will only need to report six quality measures. The three national quality strategy domains will be de-emphasized as they relate to scoring.

Among those six quality measures, you must report at least one cross-cutting measure and one outcome measure. If there is not an applicable outcome measure available, you’ll need to report a “high-priority measure.” High-priority measures include appropriate use, patient safety, efficiency, patient experience and care coordination.

Cross-cutting measures are those that help focus our efforts on population health improvement and allow for meaningful comparisons between MIPS-eligible clinicians. Most emergency physicians currently report cross cutting measure 317 (Screening for hypertension) dealing with blood pressure. The proposed rule keeps screening for high blood pressure as a cross cutting measure, but you’ll need to wait and see which options are available in the 2017 final rule, Granovsky says.

New: CMS proposes to evaluate your quality scores for all payers, not just Medicare, when you choose to submit via qualified clinical data registry (QCDR) such as ACEP’s Clinical Emergency Department Registry (CEDR), qualified registry and EHR reporting. If you currently and will continue to report via claims-based reporting and reporting via the CMS web interface, only the Medicare patients score will be used for your quality scores, Granovsky adds.

The thresholds for satisfactory reporting are increasing. The proposed reporting thresholds include 80 percent of applicable Medicare Part B patients for claims-based submission and 90 percent of all payer patients for QCDR, registry, and EHR, which represents an increase over the 50 percent threshold utilized under current PQRS reporting, Granovsky says.

If your providers can’t find enough relevant measures for their specialty or subspecialty on the specialty list, they may be able to report fewer than the required six. CMS says in the proposed rule that it will create a “validation process” similar to the measure applicability validity (MAV) process under PQRS to verify providers really are reporting enough measures.

Advancing Clinical Information (ACI): This category replaces the EHR meaningful use incentive with a weight of 25 percent of the total MIPS score.

The proposed rule exempts hospital-based providers from the meaningful use payment adjustment, Granovsky says.

CMS defines a hospital-based provider as furnishing 90 percent of his or her services in sites of service identified as an inpatient hospital or emergency room in the year preceding the payment year, or claims with Place of Service Codes 21 (inpatient hospital) or 23 (emergency department).

CMS acknowledges that there may not be sufficient measures applicable to hospital-based clinicians like emergency physicians under its proposals for the advancing care information performance category of MIPS.

Cost or resource use: This category replaces the Value Based Modifier with a weight of 10 percent of the total MIPS score in the first year

The proposed rule calls for two measures retained from Value-Based Modifier criteria of total cost per capita for all attributed beneficiaries and Medicare spending per beneficiary. In addition you can draw from over 40 measures chosen to cover various medical specialties for applicable episode based measures.

Good news: All the cost measures are obtained from claims data so no other submission method is required for these points. The cost category increases in its MIPS score weight as the program matures reaching 30 percent by 2021, Granovsky says.

Clinical practice improvement activities (CPIA): This is a new category with a weight of 15 percent of the total MIPS score.

CMS outlines nine categories covering more than 90 activities that the agency will update annually. But not all categories are equal. Some of the activities in these categories more weight than others, Granovsky explains.

The proposed rule offers an example of CPIA Performance scoring

The nine categories listed in the proposed rule are:

• Expanded practice access

Same day appointments for urgent needs and after-hours access to clinician advice.

• Population management

Monitoring health conditions of individuals to provide timely interventions or participation in Quality Clinical Date Registry (QCDR).

• Care coordination

Timely communication of test results, timely exchange of clinical information to patients and other providers and use of remote monitoring or telehealth.

• Beneficiary Engagement

Establishing care plans for individuals with complex care needs, beneficiary self–management assessment and training and using shared decision making mechanisms.

• Patient safety and practice assessment

Use of clinical or surgical checklists and practice assessments related to maintaining certification, e.g., Maintenance of Certification (MOC).

• Participation in alternative payment models
• Achieving Health Equity

Achieve high quality for underserved populations.

• Emergency Preparedness and Response

Participation in the Medical Reserve Corps.

Measuring registration in the Emergency System for Advance Registration of Volunteer Health Professionals.

Measuring relevant reserve and active duty military MIPS-eligible clinician or group activities.

Measuring MIPS-eligible clinician or group volunteer participation in domestic or international humanitarian medical relief work.

• Integrated Behavioral and Mental Health

Co-location of behavioral health and primary care services; shared/integrated behavioral health and primary care records; or cross-training of MIPS-eligible clinicians or groups participating in integrated care.

Group and Provider Are Now Both Utilized for MIPS Scoring

Under the proposed rule, MIPS performance is scored separately for each tax identification number (TIN) under which an individual bills. Using both the TIN and the NPI number allows CMS to match MIPS performance and payment adjustments with the specific group for providers that bill under more than one TIN.

The proposed rule also introduces the option for MIPS-eligible clinicians to have the flexibility to submit information individually or via a group or an APM Entity group. To be scored as a group, individual providers must aggregate their performance data for all providers working under the TIN. Importantly, a group that elects to have a group’s scoring methodology applied will be assessed at the group level across all four MIPS performance categories, Granovsky warns.

What Does This Mean For Future Year Incentives?

Based on your 2017 performance on the new MIPS categories, you will receive a composite score, which will be compared against a performance threshold based on the mean or median of the composite performance scores for all MIPs-eligible professionals.

And speaking of eligible professionals, your PAs and NPs will be included in MIPS as eligible professionals, so be sure to consider them when picking quality measures.

If you manage to score significantly better than your peers you could earn a 4 percent bonus payment form an estimated pool of $833 million. But take note that amount is budget neutral and the lowest scoring performers would have an offsetting 4 percent penalty on their 2019 payments. The MIPS-associated penalty rises to 5 percent in 2020, 7 percent in 2021 and 9 percent in 2022 so you want to be sure your group understands what is at stake and knows how to maximize the scoring in each category, Granovsky says.