ED Coding and Reimbursement Alert

The Penalty Phase begins in 2015, So Read On To Learn How to Avoid Those Cuts in your Medicare Payments

Your 2013 quality reporting will impact your Medicare payments in 2015 and beyond. Check out these strategies to position your emergency department group for the best outcome.

The skinny: The Affordable Care Act contained a provision requiring CMS to implement a value based modifier (VBM) that would apply to all fee-for-service Medicare payments.  The objective is to adjust physician pay depending on the quality and cost of the care they provide. Services provided in 2013 will be the basis for application of the VBM starting in 2015 for groups of 100 providers or more and all providers will be part of the program by 2017.

Groups Are Defined As All TIN Providers, Not Just Emergency Physicians

For VBM purposes, “group” refers to all providers under the same tax identification number (TIN), including emergency physicians, other specialties, physician assistants and nurse practioners. The number of providers in the group will be determined by checking with the Medicare Provider Enrollment Chain and Ownership System (PECOS) database assigned to that TIN, says Dennis Beck, MD, FACEP, President and CEO Beacon Medical Services in Denver, CO.

Time frame: If you have fewer than 100 providers in your group, you have a little more time to prepare, but don’t wait too long. The 2014 quality reporting period will determine the VBM adjustment for 2016 payments. The threshold number of eligible physicians to trigger the modifier application will likely be lower than 100. In any case, all eligible providers will be included in the VBM methodology for 2015 services which will be the basis for 2017 modifier application, Beck explains.

Should You Report As An Individual Or As A Group?

Eligible providers have an option to report as either an individual or a group to earn their PQRS incentive.

As an individual, your PQRS quality measures are reported using your national provider number (NPI) However, the incentive payment is provided to the TIN reporting entity. An individual may report using traditional claims using the appropriate quality data codes on the claim form as part of the billing process. You may also report through a qualified registry in 2013 if you have access to one. Of note, there is a third option of reporting via an electronic health record, but this option is generally not available to emergency physicians at this time, says Beck.

As a group, for the 2013 PQRS, CMS changed the definition of a group practice to 2 or more eligible professionals practicing under the same TIN.  Group practices with 99 or fewer eligible professionals must decide if they want to continue to report as individuals using one of the multiple reporting options for individuals described above, or if they would like to participate as a group.  Group participation is referred to as the Group Practice Reporting Option or GPRO, Beck adds.

Beginning with the 2013 reporting year, group practices of 100 or more eligible professionals will be subject to a separate Value-Based Modifier in 2015. Such groups must self-nominate to report quality data as a GPRO and then ED groups would typically elect to be reviewed using the administrative claims options. Unlike the individual reporting options, those who want to participate as a group must elect to do so by submitting a self-nomination statement via the web from July - Oct. 15, 2013. In the meantime your group practice can set up your Individuals Authorized to Access CMS Computer Services (IACS) account. Only this authorized user can elect your GPRO when the web registration system opens, warns Beck.  (For more on GPRO reporting, see “Review These Group Practice Reporting Options.”)

TOTAL POTENTIAL IMPACT OF PQRS PARTICIPATION

Understand the time line for cause and effect: It may seem like a long time in the future, but you must act now to avoid the future penalty. This is a bit confusing because the 2014 and 2015 incentives (0.5% for PQRS and 0.5% Maintenance of Certification (MOC) are actually “earned in 2013 and 2014 but paid out the following year. 2015 will be a penalty year for failure to report in 2013, says Beck.

Use 3 Steps to Avoid the Value Based Modifier Penalty Beck offers these tips to avoid the VBM penalty in 2015:

1.     Be sure your practice data is up to date and accurate in the PECOS database. Make sure both physician specialty and group practice affiliation are correct.

2.     Groups of 100 providers need to self-nominate to participate in the GPRO and elect the Administrative Claims option by Oct. 15, 2013.

3.     Satisfy the PQRS reporting criteria either by using the GPRO registry or web interface or by electing to be analyzed under the PQRS administrative Claims-based reporting option by the Oct. 15th deadline.