Gastroenterology Coding Alert

Your 2017 performance could get you 4 percent incentives in 2019.

Is surviving MACRA (Medicare Access and CHIP Reauthorization Act) your top-most worry for now? The MACRA presents a breakthrough reform in the Medicare reimbursement system, wherein all Medicare participating providers will need to score on an index of performance measures, including a mix of factors such as quality, cost, and electronic data, from 2019 onward. For a basic MACRA overview, refer to the article “MACRA Holds a $ 34 Million Promise for Gastroenterologists” in Gastroenterology Coding Alert, Volume 18, Number 7.

As you try to figure your way through, here are a few must-know facts to help you get going.

“The bigger gastroenterology practices that are well managed both in their business and medical compliance are facing the reality of MACRA and preparing,” says Catherine Brink, BS, CMM, CPC, CMSCS, CPOM, president, Healthcare Resource Management, Inc. Spring Lake, NJ.

Get the Big Picture

Beginning in 2019, you will need to participate in either the Merit-based Incentive Payment System (MIPS) or the advanced Alternative Payment Model (APM). You will have the freedom to change your options on an annual basis. While choosing the MIPS gives you payments linked to your relative performance, going on the APM track will mean you may receive higher payments, but you also have greater risk-taking capacity. Plus, the APM structure is still evolving.

Conquer the MIPS Components One at a Time

Prepare to bid goodbye to the existing three quality reporting programs: Physician Quality Reporting System (PQRS), Value Based Payment Modifier, and Meaningful Use (MU). 2016 is the last reporting period for each of these. 

In 2017, these programs, along with a new program – clinical practice improvement activities (CPIA) – will be instrumental in yielding data that will form a single score known as the MIPS Composite Performance Score (ranging from 0-100). The components of this score are:

1) Quality: This component, having 50 percent weightage in the entire score, will replace the PQRS and the quality component of the Value-Based Modifier program. You will get reporting options as per your specialty/practice, and you can choose six measures to report, instead of the nine measures required for PQRS reporting presently. “There is a great concern among practices that the measures chosen for the quality component will not be representative of true clinical quality or will be so difficult to capture that the costs or added work will significantly affect medical care delivery,” says Michael Weinstein, MD, former representative of the AMA’s CPT® Advisory Panel.

2) Cost: With 10 percent weightage, this replaces the cost component of the Value-Based Modifier Program. It will be based on Medicare claims.

3) Advancing care information: This component stands for 25 percent of the MIPS score, and is all set to replace the Electronic Health Record (EHR) incentive program (Meaningful Use). This lets you enjoy the freedom of choosing customizable measures to demonstrate how you use EHR in your practice. However, you will be required to report on six objectives:

• Protection of patient health information (PHI)
• Patient electronic access
• Coordination of care through patient engagement
• Electronic prescribing
• Health information exchange
• Public health and clinical data registry reporting. 

The American Gastroenterology Association feels that this component does have some “troubling requirements.” First, there is a full year reporting period, despite repeated requests for a 90-day reporting period. Second, a heightened focus on security and privacy may mean a zero score in case you are not able to achieve the objective of protecting PHI. “Again, the needed changes in systems and the cost of those changes will hit smaller private practices harder than larger health systems,” says Weinstein.

4) Clinical practice improvement activities: This will make up 15 percent of your total score in 2019. You will need a brand new focus on your activities to demonstrate patient safety, care coordination, and beneficiary engagement. Once again, you may pick what suits you best from a plentiful 90-odd options.

The Gastroenterology Associations are already up on their toes. “The American Gastroenterological Association (AGA), the Digestive Health Physician Association (DHPA), and other national societies will hopefully insert themselves into the measure selection process rather than have non-GI specialists or non-physicians choose,” hopes Weinstein.

Tread Well On the Tightrope of Payment Adjustments 

MIPS is a mixed bag of surprises. While you may choose to be assessed as a group or as an individual provider, get ready for a positive or a negative payment adjustment to the fee schedule, based on your performance on the MIPS score. Therefore, beginning 2019, here’s how your performance will reflect on payment adjustments – for better or for worse:

• 2019 - 4 percent (for services in 2017)
• 2020 - 5 percent (for services in 2018)
• 2021 - 7 percent (for services in 2019)
• 2022 - 9 percent (for services in 2020).

How CMS will dole out the money: CMS will calculate a payment threshold (i.e., a mean composite score for all eligible providers) during the previous reporting period. If your MIPS score matches the threshold, you will get no adjustments. If you exceed the threshold, you become eligible for the positive payment adjustment on each of your Part B claims for the next year. And in case you fall below the threshold, you will have to bear negative adjustments all through the next year for each of your Part B claims. There will be a scaling factor to ensure budget neutrality.

“Now is the time for coders and administrators to review these options and discuss their impact on their practices with the managing partners in your practice to make a decision on the direction the practice should take” says Brink.

The good side: One of the good things about the MIPS program is that the maximum 4 percent negative adjustment for 2019 works out to be significantly lower than the potential cumulative impact the existing quality and EHR programs would have had on providers.

MIPS exempt providers: The following are exempted from MIPS:

• New Medicare participants in their first year of billing
• Participants who see less than or equal to 100 Medicare patients and earn less than or equal to 10,000 Medicare dollars per year
• Participants in the advanced alternative payment model.

CMS Reserves $500 Million for Star Performers

It will be raining incentives for the physicians who are able to make it to the top 25 percent of the MIPS composite score card. For those who reach this category of exceptional performers, CMS will award a performance bonus of an additional positive payment adjustment of up to 10 percent. CMS has kept aside a dazzling trophy worth $500 million for this purpose. 

The road ahead: Get a hold on the reporting requirements for 2017 while there is still time. While most of the providers will probably opt for MIPS, choose your reporting system carefully, after assessing your eligibility and potential. As the APMs evolve, they may also offer better incentives in the long run. 

“Because gastroenterologists in academic centers will more likely participate in the alternative APM system or have administrators to collect data, the anxiety about specific measures is mostly a concern for independent private practice gastroenterologists,” says Weinstein.

To sum it up, “I would stress coders and administrators thoroughly review the difference between choosing MIPS vs. APMs, meaning the long range financial implications. Since this is time sensitive, it is more than prudent to do this now,” says Brink.

Editor’s note: Stay tuned for how to reap more from APMs in the next issue.