Neurosurgery Coding Alert

You can choose form MIPS and APMs.

Physician payment programs, established by the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, receive recent attention. In an attempt to streamlining and strengthening value and quality-based payments for all physicians, CMS has issued a Proposed Rule for its new Quality Payment Program.

The new program rewards value and quality of care through two pathways:

• Merit-based Incentive Payment System (MIPS)
• Advanced Alternative Payment Models (APMs)

Choose one over the other: Clinicians will enjoy flexibility regarding their participation in the new payment system. Clinicians can opt to move to another pathway as the proposed rule aligns standards between the two pathways of the Quality Payment Program (MIPS and Advanced APM).

“The challenge for specialists is participation with Advanced APMs.  These require certified EHR technology, based on quality measures, and must bear more than nominal financial risk among other requirements,” says Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison.

Criteria to opt out: In order to opt out of the MIPS payment adjustment for 2019 and 2020, the clinician must receive 20 percent of their Medicare payments through an Advanced APM or must see 10 percent of their Medicare patients through an Advanced APM.

Cost and quality are key in MIPS

MIPS, the single new reporting program, combines and streamlines the requirements of the Physician Quality Reporting System, the Value Modifier Program, and the Medicare Electronic Health Record (EHR) Incentive Program.

Performance period and payment year for MIPS: The first performance period for MIPS would be from January 1, 2017 through December 31, 2017. The first payment year for MIPS will be 2019, based on the first performance period of 2017.

MIPS applies to Medicare Part B clinicians: All Medicare Part B clinicians, including physicians, physician assistants, nurse practitioners, clinical nurse specialist, and certified registered nurse anesthetists, will report through MIPS during the first performance year, beginning January 2017.

Exemption may apply: Medicare Part B clinicians may be exempted from the payment adjustment under MIPS if they are newly enrolled in Medicare, have ≤$10,000 in Medicare charges and ≤100 Medicare patients, or are significantly participating in an Advanced APM.

“There are lobbying efforts underway to allow physicians more time to learn about and prepare for participation in these programs,” Przybylski says. “While payment adjustments are more than two years away, the performance year on which the first adjustments will be based is less than six months away.”

Performance categories in MIPS: According to CMS, MIPS will allow clinicians to be paid for providing high quality, efficient care through success in four performance categories:

• Cost
• Quality
• Clinical practice improvement activities
• Advancing care information

Clinicians Earn Credits and Incentives

Clinicians can look forward to rewarding incentives for high-quality, efficient, and coordinated care.

Models qualifying for advanced APMs: Clinicians may opt to participate in Advanced APMs, such as the Comprehensive ESRD Care Model, Comprehensive Primary Care Plus (CPC+), Medicare Shared Savings Program—Track 2, or the Next Generation Accountable Care Organization (ACO) Model.  CMS will continue to modify models in coming years to help them qualify as Advanced APMs. “The qualified advanced APMs are particularly geared to primary care and not specialty practices,” Przybylski says.

Annual updates apply: Under the proposed rule, CMS would update this list annually to add new payment models that qualify.

Rewards in Advanced APMs: MIPS participants who participate in APMs would receive credit in the Clinical Practice Improvement Activities category. Clinicians who meet Advanced APM participation requirements are exempt from MIPS payment adjustments and will qualify for a 5% incentive payment.

MIPS is the initial step: To determine whether clinicians can qualify for the Advanced APM track, all clinicians will report through MIPS in the first year.

Know more: For more information about the CMS proposals, check the Fact Sheet on the CMS website: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/NPRM-QPP-Fact-Sheet.pdf.