Oncology & Hematology Coding Alert

Upcoming changes include full-year reporting, increased payment adjustments

Are you familiar with the Medicare Access and CHIP Reauthorization Act (MACRA) law, the cornerstone legislation helping to shift physician reimbursement from fee-for-service to value-based reimbursement? You should be. And if you participated as fully as you could during the 2017 transition year, you could be well-positioned for success in 2018.

The final rule detailing CY 2018 Updates to Medicare's Quality Payment Program-released in November-is very similar to the proposed version that was released in June. But as always, there are changes on the horizon. Read on for all the guidance you need on what's new, what's different, and what to do to ensure your practice's profitability in the long run.

1. You will have to do more work.

In 2017, you could "pick your own pace" of participation, but that changes beginning in January. "It's gonna be tougher," says Mike Schmidt, director of client certification and success at Medflow. But "it's quite feasible to get a perfect score if your performance is there," he says. Here's what's changed:

• You must report quality measures for the full calendar year (not just ninety days as was the case for 2017). You'll need a minimum of six measures total, including one outcome measure. Quality counts for fifty percent of your MIPS score.

Helpful Hint: You can view the General Oncology Measures Set, consisting of nineteen measures, at qpp.cms.gov/mips/quality-measures.

• CMS will also start counting the Resource Use category. This was not included in your 2017 MIPS score, but will count for ten percent of your score in 2018.
• The performance threshold has been raised from three percent to fifteen percent. You must submit enough measures to achieve a final MIPS score of at least fifteen out of one hundred. If you don't meet the minimum, you'll be facing a five percent penalty in 2020.

2. The stakes are higher.

The possible payment adjustment you're subject to will increase by one percent. In 2017, it was four percent. In 2018, it will be five percent. CMS has also added a "scoring improvement" component to the Quality and Resource Use categories. "If you do better and better on your score every year, you get a little extra bonus for improving," says Schmidt.

Cost measures will be risk-adjusted by specialty, but succeeding in the Resource Use category may be particularly challenging for oncologists, according to Robin Zon, MD, FACP, a medical oncologist at Michiana Hematology Oncology in South Bend, Indiana.

Zon, who also chairs the American Society of Clinical Oncology (ASCO) Government Relations Committee and is member of ASCO's MACRA Task Force, told Oncology Practice Management that this is because Medicare Part B drugs are currently included in Merit-Based Incentive Payment System (MIPS), while Part D drugs aren't. Remember that you're being scored in comparison to all participating physicians, nationwide. "If we're going to provide our patients with value, we're going to have to give the right drug, at the right time, to the right patient, and those are typically very expensive drugs," she said.

3. There's protection for small practices-sort of.

"The challenge of MIPS is that CMS estimates that it would negatively impact small practices in a disproportionate way," says Schmidt. To remedy that, the 2018 final rule features several safeguards aimed at protecting small practices-those with fifteen or fewer clinicians. They include:

• Raising the low volume exclusion from $30,000 to $90,000 in billable Medicare charges.
• Giving small practices five bonus points just for overall participation in MIPS, and three bonus points for quality measures, even if they don't meet completeness requirements (a twenty case-minimum, for example).

But small practices aren't the only ones that could benefit from those bonuses. They are "actually assessed per group tax ID number (TIN)," notes Schmidt. "If you're a large group practice and you have multiple TINs, as long as each one of those TINs has fewer than sixteen physicians billing to Medicare, you'd be eligible for this small practice bonus."

There is also an option for virtual groups "that is kind of complicated," says Schmidt. Virtual groups are intended to allow small practices to band together for group reporting.

Warning: Providers in virtual groups with more than fifteen participants overall would lose their other small practice accommodations.

4. You may not be able to DIY it.

Due to the "pick your own pace" options for the 2017 transition year, you may have had an easy time meeting the minimum MIPS requirements this past year. But don't let that lull you into a false sense of security come January 2018. You will no longer be able to submit one quality measure, clinical practice improvement activity (CPIA), or advancing care information (ACI) requirement and be done with it.

"The challenge with understanding MIPS is that you have to see the big picture, but also be aware of the critical small details," explains Schmidt, and "build a roadmap for success that is tailored to your practice." All of that does take time and effort, Schmidt acknowledges, but "it's worth doing resource planning. There's enough money in play that makes it worth it."

According to Schmidt, the required expertise for MIPS compliance includes someone with:

• Solid working knowledge of the oncology workflow
• A thorough understanding of current and evolving MIPS regulations
• Expert-level familiarity with your practice's EHR technology and other health IT solutions
• Availability to be involved before, during, and after each performance year with no break between

"You can do it with in-house resources, but you need to plan on at least a twenty percent load on a full-time resource to do the job effectively," says Schmidt. "If you have enough time with the sufficiently knowledgeable resources, go for it. Most practices either don't have the right resource or they're just too busy."

5. You can't depend solely on your registry.

"We encourage you to use a registry that is electronically integrated with your EHR to earn the bonus points for electronic reporting," recommends Schmidt, but "they really can't be counted on to own your practice's overall MIPS success," he warns. Registries such as the Quality Oncology Practice Initiative Reporting Registry assist you with MIPS because they can capture and aggregate your raw quality data, Schmidt explains.

Bottom Line? Registries make reporting easier, but don't look to them for every answer. "There are individuals [with the registries] that are really fantastic that work with practices, but really their mission for their company is not to ensure your practices success, it's to run their registry."

Resources: CMS has a startlingly clear, usable website about MACRA, MIPS, APMs, and value-based reimbursement: https://qualitypaymentprogram.cms.gov/. At press time, they haven't updated instructions for 2018 on this site, but you can subscribe to updates that alert you to when new information is posted.

For a primer on MACRA and MIPS, see the story below.

For more on APMs, see the story on page 4.

Read the final MACRA rule for CY 2018 at:>https://s3.amazonaws.com/public-inspection.federalregister.gov/2017-24067.pdf?utm_campaign=pi subscription mailing list&utm_source=federalregister.gov&utm_medium=email.