Pathology/Lab Coding Alert

Avoid big penalties that start in 2015.

If you’re already participating in the Physician Quality Reporting System (PQRS), you have some decisions to make by Oct. 15. Ignoring your options now could mean losing your bonus — or even facing a penalty — in years to come.

Rewind: Pathologists (except those who file claims using place of service 81 [Independent laboratory]) have five available quality measures. Although you can currently get a bonus for PQRS participation, a provision in the Affordable Care Act (ACA) could change all that. Let our experts walk you through what you can do to get ready — and what it can mean to your Medicare pay.

Helpful tool: See “Check Out This PQRS Pathology Summary” on page 77 to review the pathology quality measures.

Step 1: Understand How ‘Bonus’ Can Turn to ‘Penalty’

The ACA authorizes PQRS incentive payments (currently 0.5 percent) through 2014, but the bonus might turn to a penalty in 2015 and beyond. Physicians who are eligible to participate in PQRS in 2013 but choose not to will be paid 1.5 percent less than the Physician Fee Schedule (PFS) amount for that service in 2015. For 2016 and subsequent years, the payment penalty is 2.0 percent, according to CMS.

On the other hand, physicians who participate in PQRS might continue to get incentive payments based on an ACA provision that establishes a value-based payment modifier (VBPM) that would apply to all fee-for-service Medicare payments.

The value modifier will either be 0 percent, negative 1 percent, or an upward, downward, or no payment adjustment if you elect “quality tiering.” Decide where you fit in this range by reading on through the next steps.

Step 2: Determine Your Group Size

For VBPM purposes, CMS defines a group of physicians as “a single taxpayer identification number (TIN) with two or more individual eligible professionals, as identified by their individual national provider identifier (NPI) who have reassigned their Medicare billing rights to the TIN.”

Allowing two to count as a group is new for 2013. In 2010 CMS defined a group as practices “with over 200 eligible professionals (providers),” explains Jill M. Young, CPC, CEDC, CIMC, principle of Young Medical Consulting LLC in East Lansing, Mich. 

The number of providers in the group will be determined by checking with the Medicare Provider Enrollment Chain and Ownership System (PECOS) database assigned to that TIN, says Dennis Beck, MD, FACEP, president and CEO of Beacon Medical Services in Denver.

Timeline: For groups of 100 providers or more, services provided in 2013 will be the basis for applying the VBPM to payment in 2015. If you have fewer than 100 providers in your group, you have a little more time, but don’t wait too long — all providers will be included in the VBPM methodology for 2015, which will be the basis for 2017 modifier application, Beck explains.

Step 3: Choose ‘Individual’ or ‘Group’

Eligible providers have an option to report as either an individual or a group to earn their PQRS incentive.

Heads up: If you’re currently participating in PQRS as an individual physician and do nothing, you’ll face the negative 1 percent value modifier payment adjustment. If you’re part of a group of two or more eligible providers, you can avoid that fate by doing one of the following:

• Self-nominate/register for PQRS as a group by Oct. 15, 2013 and report at least one measure. You’ll also need to select your reporting mechanism by that date (see step 4). Group participation is referred to as the Group Practice Reporting Option or GPRO, Beck says.

        OR

• Elect the PQRS Administrative Claims option as a group by Oct. 15, 2013 if you’re part of a group whose physicians want to continue to participate in PQRS as individuals. If you do this, the individual physician can continue to report by putting the appropriate quality data codes on the claim form as part of the billing process

Pros and cons: The advantage of GPRO is that your bonus calculation will be based on allowed charges of all physicians in the group — even those who don’t report PQRS measures. On the down side, you’ll be required to report each code for a minimum of 80 percent of all eligible cases to be considered for the bonus — compared to a 50 percent benchmark required for individuals.

If you register either for GPRO or elect the Administrative Claims option by Oct. 15, you’ll avoid the negative 1 percent value modifier. But what will your modifier be instead?

Answer: The modifier will be 0, unless you make the Quality-Tiering election by Oct. 15. If you make that election, CMS will use the performance rates on your quality measures to calculate a VBPM that will result in an upward, downward, or no payment adjustment based on performance. 

Step 4: State Your Reporting Mechanism

If you’re reporting your quality data using the group designation, you’ll need to select your reporting mechanism by the Oct. 15 deadline. “There are different options, and you have to look at what is most appropriate for you,” Young explains.

GPRO Web Interface: This option is available only to group practices of 25 or more eligible professionals who have self-nominated/registered as a group.

CMS-Qualified Registry: Group practices of two or more may report through qualified registries. If your practice has self-nominated/registered as a group, the registry is your only option besides the web interface — you can’t file claim by claim. However, those choosing the Administrative Claims Option may also choose to report through a qualified registry.

PQRS Administrative Claims Option: With this option, you can choose to file claim by claim or through a registry. CMS has agreed that for groups who elect this option, even if they have a denominator of zero for all measures, they can still avoid the 2015 PQRS penalty.