Pathology/Lab Coding Alert

Small pathology practices find relief under QPP proposed rule.

Maybe you’ve barely digested Medicare’s 2017 Quality Payment Program (QPP) final rule, but the 2018 proposed rule is out, and it has some changes you need to know now.

Good news: The proposed rule offers some help for Medicare Part B clinicians struggling with quality reimbursement requirements. These include reduced thresholds and reporting burdens, eased CEHRT mandates, small-provider assistance, and more.

See What CMS Says

Read the proposed rule, published in the Federal Register on June 30, at www.federalregister.gov/documents/2017/06/30/2017-13010/medicare-program-cy-2018-updates-to-the-quality-payment-program.

“We’ve heard the concerns that too many quality programs, technology requirements, and measures get between the doctor and the patient,” said CMS Administrator Seema Verma in a CMS press release from June 20, 2017. “That’s why we’re taking a hard look at reducing burdens. By proposing this rule, we aim to improve Medicare by helping doctors and clinicians concentrate on caring for their patients rather than filling out paperwork.”

Name change note: In order to avoid confusion over the changes and to distinguish the 2017 information from the 2018 details, the CMS will now refer to the second year of the program as “The Quality Payment Program Year 2” rather than “pick your pace.”

Are You Subject to MIPS Reporting?

One of the major updates under the 2018 proposed rule concerns the Merit-Based Incentive Payment System (MIPS) low-volume threshold. This part of the QPP Year 2 offers relief to Medicare Part B providers struggling with reporting measures.

Transition year 2017: CMS guidance is very specific about who participates in MIPS for 2017. If you bill Medicare Part B more than $30,000 in payments a year and see more than 100 Medicare Part B-enrolled patients annually, then you are required to report measures under MACRA — for CY 2017. However, if you don’t meet this year’s low-volume threshold, you are exempt from reporting for 2017 and can avoid the 4 percent penalty to your reimbursements paid out in 2019.

Big news for 2018: Under the QPP Year 2 proposed rule, the low-volume threshold would be increased, easing the burden substantially. To be subject to MIPS in 2018, the proposal suggests 200 Medicare Part B beneficiaries or $90,000 in Part B allowed charges be the new threshold.

The positive: Despite the added confusion with the threshold increase, CMS did respond to the public outcry instead of steamrolling over a year’s worth of providers’ complaints, adjusting the QPP Year 2 accordingly. “It shows that CMS is continuing to listen to feedback from providers about the burdens individual and small groups related to the payment reform have,” maintains attorney Benjamin Fee, Esq. of Dorsey and Whitney LLP. in the Des Moines, Iowa office.

“While CMS estimates that 134,000 additional clinicians will be excluded from MIPS as a result of the increased threshold levels, it also estimates that 65% of Medicare payments would still be captured under MIPS,” Fee explains.

Note More Proposed Developments

Raising the participation threshold isn’t the only recommended change for 2018 — you’ll see the following plans in the proposed rule as well:

Delay cost: CMS proposes to keep the cost category weighted at 0 percent for 2018 rather than increasing it to 10 percent as planned. Although this will relieve the administrative burden in 2018, remember that CMS is required by law to weight the cost category at 30 percent in 2019.

Increase reporting period: Although CMS proposes to keep the performance period at 90 days for Improvement Activities and Advancing Care Information categories, the performance period for Quality and Cost categories will increase to a full calendar year in 2019, according to the proposed rule — an increase from the current 90 days.

New ways to participate:

• “CMS has proposed to allow clinicians or groups to potentially opt-in to MIPS beginning in performance year 2019 even if the clinician or group does not meet both the low-volume threshold components,”
• notes attorney Alissa Smith, Esq. of Dorsey and Whitney in the Des Moines, Iowa office. This is great news for clinicians or groups who’d like to participate but only satisfy one of the threshold requirements. “CMS is also proposing to potentially add a third component based on the number of Part B items or services provided,” Smith adds.
• For 2018, CMS will also allow practitioners and small practices who don’t meet the threshold to band together into “virtual groups” to aggregate data for participation in MIPS.
• If you are a hospital-based pathologist, you might also be able to participate in MIPS in 2018 by submitting your facility’s inpatient value-based purchasing score.

Update non-patient facing: The 2018 proposed rule keeps the definitions of non-patient facing clinicians the same, except adds virtual groups to the definition. Recall that a non-patient facing clinician bills less than 100 patient encounters per calendar year, and a non-patient-facing group is one in which at least 75 percent of eligible providers are non-patient facing.

Most pathologists are non-patient facing because they seldom see patients face-to-face. This is important because CMS requires reporting for fewer measures if you’re non-patient-facing. Although you must still report data for up to six Quality measures, you must attest to just two Clinical Practice Improvement Activities (CPIA) (compared to four for patient-facing clinicians), and you are exempt from the five required measures in the Advancing Care Information (ACI) performance category.

Delay CEHRT: The proposed rule would allow continued use of 2014 Edition Certified Electronic Health Record Technology (CEHRT) rather than requiring an update to the 2015 edition by 2018.

Resource: To review the CMS factsheet on the CY 2018 updates to the Quality Payment Program, visit qpp.cms.gov/docs/QPP_Proposed_Rule_for_QPP_Year_2.pdf.

Caution: All of these changes are proposed, and may change when CMS releases the final rule this fall.