Gastroenterology Coding Alert

Solo practices to be hit hard, large practices to flourish, and more …

Tighten your seat belts, as your journey of transition to the new MACRA (Medicare Access and CHIP Reauthorization Act) framework begins now. On April 27, CMS disseminated the proposed rules for implementation of the MACRA. With the Final Rule expected in fall 2016, it’s time now to get ready with your action plan. Here is what the American Gastroenterology Association’s (AGA) report on MACRA says the ruling has in store for you.

Background: MACRA is all about an overhaul of existing programs on physician payment, rolling out a Merit Based Incentive Payment System (MIPS) and Alternative Payment Models (APM). Currently, there are three existing quality incentive programs including:

• Physician Quality Reporting System (PQRS) 
• EHR Meaningful Use
• Value-Based Modifier.

“The MACRA proposed rule contains many improvements from existing requirements, but contains strict requirements for many activities,” says the AGA report, May 2016, on Proposed Medicare and Quality Reforms.

Be careful on how you perform on Medicare’s quality measures and standards in 2017, as this will impact your payments in 2019, says AGA.

Starting in 2019, these will become one single program to ease reporting and reduce paperwork. So, get ready for adjustments in your future payments based on your performance in areas of quality, EHR meaningful use, resource use, and clinical practice enhancement endeavors.

What’s In It for You?

AGA shares information on the significant impact this act may have on gastroenterology practices:

• A positive adjustment of $34 million, offset by $16 million negative adjustment for gastroenterologists.
• CMS estimates that a good majority, 61.5 percent, of gastroenterologists who participate in MIPS will receive a bonus; however, there would also be negative payment adjustments for 38.3 percent of GI physicians.
• Solo practices are to be hit the hardest.
• CMS data shows the likelihood of receiving an upward performance adjustment increases as the practice size increases. Practices with 100 or more clinicians are expected to benefit the most.

Questions in your mind? What made CMS determine so early that 38 percent of the GIs would not deserve incentives? You may also be curious to know about the mathematics behind this. How a group of providers are at an advantage in terms of incentives, as compared to solo providers? How is the quality of performance related to numbers? These are important questions; to get to the answers, we need to dig deeper into CMS database analytics for gastroenterologists, and stay tuned to the latest updates on this front.

What It Means to Your Bottom Line

MACRA would entail a five-year transition period, leading to a better quality and value based Medicare program. To this effect, the proposed rule has strict requirements for basically two types of payment models.

1) Merit-Based Incentive Payment System (MIPS)

MIPS will replace the current reporting systems. It will apply upward or downward reimbursement adjustments based on performance in four categories:

• Quality
• Advancing care information (electronic health records)
• Clinical performance improvement activities
• Resource use.

Remember: Most GIs will need to participate in MIPS.

2) Alternative Payment Model (APM)

Physicians may want to avoid the MIPS penalties and opt for getting a lump-sum incentive by participating in the Alternative Payment Models (APMs). They would still need to adhere to stringent quality standards and also fulfill risk-sharing requirements. APMs are most appropriate for larger systems, and focus on care coordination as well as sharing of financial risk.

However, as of now there are no gastroenterology specific APMs. Moreover, given the complexities of establishing an APM, this option would be impractical in the first year for many smaller practices and solo practitioners.

Do You Fall in the MIPS Exclusion Criteria?

CMS has created a low volume cut-off threshold, below which you will be excluded from MIPS. According to the proposed rule, if you see less than 100 Medicare Part B eligible patients and bill less than $10,000 to Medicare every year, you do not need to participate in MIPS. Apart from this, new Medicare participants and those who opt for APMs, all would be exempt from MIPS. In total, CMS has calculated that 1,849 such gastroenterologists may not be able to participate in MIPS, due to various reasons.

Mint dollars with quality care: It may interest you to know that in addition to the general positive payment adjustment, “CMS will begin by providing $500 million worth of exceptional performance payments, of which $13 million is expected to go to gastroenterology,” as per the AGA report.

The future: “An early analysis of MIPS participation suggests that the costs in terms of time and money will be beyond what a small practice can tolerate,” contemplates Michael Weinstein, MD, former representative of the AMA’s CPT^® Advisory Panel. “Large multi-specialty groups and hospital system employed physicians will have options that are not as costly or imposing on their time. The Digestive Health Physicians Association (DHPA) representing about 1,400 physicians in large groups is actively seeking regulations that provide opportunities for single specialty practices to participate in APMs. Both the AGA and DHPA provided comments to CMS and dozens of our elected representatives pointing out needed changes on behalf of gastroenterologists. All gastroenterologists should be willing to send comments to try to achieve a fair result and their societies will provide some guidance as the process proceeds.”

All that said, there is still time. “There is a two year gap between the time that reimbursement changes are applied and when services are provided,” says the AGA report. Therefore, plan your 2017 work strategies in accordance with the benefits you wish to accrue in 2019. Stay tuned to the latest developments, as the final rule is expected to arrive in fall 2016.

Editor’s note: In the next issue, look out for the must-know MIPS requirements for gastroenterologists.