Orthopedic Coding Alert

Embrace MIPS as PQRS wanes.

If you think that the expiring Physician Quality Reporting System (PQRS) means your orthopedic practice can forget about “quality reporting,” think again.

In fact, quality reporting moves forward in an even bigger way under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which “represents the most significant change to Medicare’s physician payment system in a generation …” according to Andrew Gurman, MD, AMA president, in a press release responding to the final rule.

Bottom line: You can’t afford to ignore what MACRA means for your practice if you want to preserve your Medicare pay this year and moving into the future. Don’t let your practice reflect a recent survey performed by The Physicians Foundation that “found that only 20 percent of physicians are familiar with MACRA,” according to Sarah Warden, Esq., of Greenspoon Marder in Ft. Lauderdale, Florida.

“Orthopaedic practices who are required to report under MIPS should not find it that difficult to select among the appropriate measures, and, as discussed below, small steps can lead to at least some payment incentives,” says Bill Mallon, MD, former medical director, Triangle Orthopedic Associates, Durham, N.C.

Do this: Study the following Q&As to make sure you have the tools you need to maximize your reimbursement — or at least avoid pitfalls that will result in a negative payment adjustment for your providers.

Question: How does quality reporting under MACRA relate to earlier programs such as PQRS, EHR, and VM?

Answer: Before MACRA, Medicare paid physicians based on a fee-for-service structure called the Sustainable Growth Rate. However, CMS had instituted several quality reporting initiatives in recent years, such as Physician Quality Reporting System (PQRS), Electronic Health Record (EHR) incentive program called “Meaningful Use,” and Value-Based Payment Modifier (VM).

These began as voluntary programs and varied in payment impact from neutral, to small incentives, to penalties. In fact, eligible clinicians who didn’t report PQRS measures for 2016 services can expect a 2 percent payment reduction from Medicare Physician Fee Schedule rates in 2018, according to Carol Jones, MSN, CMS Program Analyst, in an MLN Connects National Provider Call earlier this year.

Under MACRA, CMS phases out data collection for any of the previous programs for services beginning Jan. 1, 2017 (although data reporting from performance-year 2016 continues into 2017). Instead, you’ll have a new Quality Payment Program (QPP) with two paths: Advanced Alternative Payment Model (APMs) (which most practices won’t qualify for this year), or Merit-Based Incentive Payment System (MIPS).

Important: Eligible clinicians must report data using MIPS in 2017 or face payment penalties in 2019.

MIPS aims to evaluate performance under four categories, three of which parallel the three terminated programs, as follows:

• Quality — primarily replaces PQRS
• Advancing Care Information — primarily replaces Meaningful Use of EHR
• Cost — primarily replaces VM
• Improvement Activities — new quality category for evaluation.

Clinicians will receive a score in each category, which CMS weights according to the relative importance assigned to each, to arrive at a single score between 0 and 100. The category weight may change over time and based on clinician characteristics.

Question: Is participation in MIPS “all or nothing” in terms of getting a payment incentive or penalty?

Answer: No, MIPS is not all or nothing, especially in 2017 when CMS actually makes it easy to avoid the penalty. The MIPS program comes with a “pick your pace” option that allows you to start your reporting as small or as big as you’re ready to go. Here are the participation categories and the rewards or penalties for each:

• Non-participation: If your orthopedist is eligible for MIPS and does nothing in 2017, you can expect a negative 4 percent adjustment to payment in 2019.
• Test: If you just try out MIPS — say one quality measure for one patient, or one improvement activity — you’ll avoid the 4 percent penalty. This is a no-brainer, people.
• Partial year: For submitting data for 90 days in 2017, you may earn a small positive payment adjustment.
• Full year: You can earn a moderate payment increase for a full year of reporting data.

Question: Are any clinicians “exempt” from QPP to earn incentives and avoid penalties?

Answer: Clinicians who meet the “low-volume” threshold don’t need to participate in a QPP. Low volume means seeing 100 or fewer unique Medicare patients a year, or having $30,000 or less in annual Medicare Part B allowed charges. And this can work in your favor in two ways: If your practice saw more than 100 Medicare patients, but submitted claims that totaled less than $30,000 for these patients, you would be exempt. Conversely, if you saw only 50 Medicare patients with total charges of $45,000 you would still be considered exempt. CMS has indicated that they will calculate the low-volume thresholds for all providers/practices and by now you should have been notified by them whether you are exempt from reporting in 2017. The notification period was planned from December 2016 to February 2017. Also, clinicians newly-enrolled in Medicare are exempt in their first year, according to Molly MacHarris, CMS Health Insurance Specialist, in a the recent MLN Connects National Provider Call.

Question: What are the reporting requirements for the four MIPS performance categories?

Answer: The reporting requirements are as follows:

Quality — Eligible clinicians need to report six quality measures (compared to nine under PQRS) or a specialty measure set. One of those must be an outcome measure (if available) or a high-priority measure if no outcome measure is available. To meet the measure, clinicians should report on 50 percent of patients in 2017, growing to 60 percent in 2018 and possibly more in later years. See “Highlight These 21 Quality Measures for Your Orthopedic Practice” on page 27 for a list of orthopedic measures.

Cost — This category is based on claims, and carries no weight for eligible clinicians in 2017. However, the cost category will increase to 10 percent in 2018 and 30 percent in 2019 and beyond.

Advancing Care Information (ACI) — Eligible clinicians need to report on all base-score measures (four in 2017, five in 2018) and up to nine optional measures for a higher score. The reporting period is 90 days for 2017 and 2018, but will increase to the full year. You can read about the ACI measures at https://qpp.cms.gov/measures/aci.

Improvement Activities — Eligible clinicians should report a total of 40 points-worth of improvement activities (such as two-high weighted or four-medium weighted activities). You can find a list of activities at https://qpp.cms.gov/measures/ia.

You can read more about performance measures at https://qpp.cms.gov/measures/performance.