ED Coding and Reimbursement Alert

Along with several new acronyms like VBM and MAV you'll need to know

When the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) became law last year it removed the dreaded sustainable growth rate formula, which continually threatened to lower the Medicare conversion factor. But it replaced the SGR with the new merit based incentive program. Check out these MIPS tips to help you prepare for 2016 and beyond.

Meet the Merit-Based Incentive Program

The Merit-Based Incentive Payment System (MIPS) is a payment mechanism that will provide annual updates to physicians starting in 2019 based on performance metrics including: quality, resource use, clinical practice improvement activities, and meaningful use of an electronic medical record (EMR) system.

Note: Overall meaningful use requirements are being softened by the current administration and are unlikely to apply to ED physicians in particular.

Unlike the flawed SGR, the new system will adjust payments based on individual performance. Importantly, MIPS does not set an arbitrary aggregate spending target, which previously led to the need for annual patches to prevent SGR-mandated cuts. The three existing quality programs (PQRS, VBM, and Meaningful Use) will be consolidated under MIPS beginning in 2019, says Michael A. Granovsky, MD, FACEP, CPC, President of LogixHealth, a national ED coding and billing company based in Bedford, MA.

Keep Current with Physician Quality Reporting System

Caution: Although MIPS is coming, the PQRS program will continue for 2016. Groups not reporting PQRS measures in 2016 will receive a two percent penalty assessed against their 2018 Medicare allowable payments. But the impact is greater than just two percent. Failing to satisfy 2016 PQRS reporting requirements will also trigger an additional four percent penalty for most groups under the value based modifier (VBM) program for a total penalty of six percent in 2018.

To avoid those future penalties, PQRS reporting requires at least nine measures, involving three National Quality Strategy domains, for at least 50 percent of your Medicare patients during 2016. You'll also need to include a cross cutting measure to satisfy CMS reporting requirements, Granovsky warns. Cross-cutting measures are measures that are broadly applicable across multiple clinical settings and eligible professionals or group practices within a variety of specialties and were new for 2015, Granovsky explains.

As in 2015, there are a limited number of ED-relevant performance measures available, and it is not realistic for most emergency physicians to be able to report nine measures across three domains. The table below shows the commonly available ED Related measures for 2016.

Table1: Available Typical ED Related PQRS Measures for 2016

Welcome New Emergency Medicine Cluster for 2016

CMS listened to the emergency medicine community and realized it was not possible to successfully report in the traditional manner. To provide an interim solution for 2016, CMS created Cluster 4 for emergency medicine.

Important: Although it's not listed in the cluster, CMS still requires a cross-cutting measure

Cross Cutting Measure 317 Is Still Available

The 2016 Final Rule had originally removed the ED E/M codes (99281-99285) from crosscutting measure # 317 (screening for hypertension). Although that measure was not a perfect option for emergency medicine, it was available for reporting last year. This allowed emergency physicians to satisfactorily report PQRS when they would not otherwise have been able to do so, given the absence of other meaningful crosscutting measures. A new measure was added for ED use, # 1 (Diabetes: Hemoglobin A1C Poor Control-Claims and Registry-Cross-Cutting Measure), which required drawing HgA1C. Groups would score well if the result was less than 9 percent. However, CMS relented and made measure 317 available again for 2016, says Granovsky.

CMS Uses a Multi-Step Process For Scoring PQRS Reporting

On Nov. 17 2015, CMS released a guidance document to delineate the MAV process and requirements for those individual eligible providers that are unable to report on nine measures across three domains. To validate that there were no other measures applicable to the reporting providers practice, CMS will review the reported measures linked to a cluster, such as emergency medicine cluster 4, that are related and likely applicable to a practice. Additional measures that may have been applicable to the individual provider's practice maybe identified by this two-step validation process:

Step 1: Measure Applicability Validation (MAV) Clinical/Domain Relation Test

The MAV Clinical Relation/Domain Test is based on:

1. If an individual eligible professional (EP) or group practice reports data for a measure, then that measure applies to their practice, and

2. The concept that if one measure in a cluster of measures related to a particular clinical topic, or individual EP, or group practice service is applicable to an individual EP's or group's practice, then other closely-related measures (measures in that same cluster) would also be applicable.

Step 2: Minimum Threshold Test

The provider needs to achieve a minimum of 15 denominator eligible events for a measure to count. "The common minimum threshold, based on statistical and clinical frequency considerations, will not be less than 15 encounters for the reporting period for each 2016 PQRS measure," according CMS.

This is why it is unlikely for emergency physicians to be able to successfully report measures 254 (Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain) or 255 (Rh Immunoglobin [Rhogam] for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure) dealing with pregnant patients in the Medicare population. The chances that an individual emergency physician will see 15 such patients in a year are extremely unlikely.

Where Does The MAV Fit In?

If an eligible Medicare provider reports fewer than nine measures available the provider will fall under the Measure Applicability Validation (MAV) calculation

CMS recognizes that a limited number of individual eligible professionals may not be able to identify nine measures covering three domains that are applicable to their practice.

The Measure Applicability Validation (MAV) process exists to help individual eligible professionals who might practice in specialties that have a limited number of measures for which they can report, to appropriately avoid the payment adjustments. However, MAV is an analytically complex process. If the MAV process shows that a provider should have reported more measures, 2018 payment adjustments may apply.

Take a Closer Look at the 2016 Value-Based Payment Modifier (VBM)

The Affordable Care Act requires CMS to apply a VBM to physician payments for all providers by 2017. CMS has been gradually phasing in the VBM program, which aims to incentivize physicians to provide high quality and cost effective care. Because it is a budget neutral program, there will be penalties for low performers to offset the bonuses for high performers.

Take note: The VBM applies at the tax identification number (TIN) level and fifty percent of all eligible providers under the TIN must satisfy PQRS reporting requirements. This includes all physicians and advanced practice providers, full time and part timers.

The VBM scoring methodology looks at both cost and quality scoring for individual providers and groups. Failing to meet the PQRS reporting requirements will trigger an automatic four percent penalty under the VBM program. Groups satisfying PQRS reporting go on to the quality-tiering step and will be graded as below average, average, or above average and have the potential to earn a small bonus.

Change: As MIPS takes over in 2019, expect VBM to phase out after 2018.

Incentive Percentages for Groups of 10 or More Providers

Groups of 2 to 9 providers have smaller available bonuses, but no penalties at risk for low quality ratings

* Eligible for an additional +1.0x if reporting measure and average beneficiary risk score in the top 25 percent of all beneficiary risk scores.