Podiatry Coding & Billing Alert

MACRA Is replacing the Sustainable Growth rate formula that was used for years to update Medicare payment rates with the Quality Payment Program (QPP). The QPP has two payment models that revise the old system and one new model that focuses on performance in familiar categories.

QPP is designed to reward Medicare providers for quality care, rather than paying them based on the number of services they provide. The value-based medicine that MACRA promotes gives payers a way to rein in the high costs of healthcare by implementing variations on the reimbursement model. With MACRA, CMS intends to provide better care to patients, encourage smarter spending, and increase Americans' health.

If you want to continue receiving reimbursements on the services you provide for your Medicare patients when the first performance year begins January 1st, 2017 - and if you are eligible to participate in the QPP - you have to use one of the new payment models: merit-based incentive payment system (MIPS) or the alternative payment method (APM).

If you go with MIPS, you'll still be paid for the services you provide, but MIPS will determine whether you receive a plus or minus adjustment (of up to 9 percent) to what you are paid - based on your performance in those areas. MIPS includes elements of the Physician Quality Reporting System, the Value-based Payment Modifier, and the Medicare Electronic Health Record incentive program. Under MIPS, penalties and rewards will be dependent upon a practice's performance in four areas.

If you opt to use the MIPS model, you'll want to understand exactly what you have to do to perform well in each of the four MIPS categories. These categories combine the three current independent programs of Meaningful Use, PQRS, and the Value-Based Modifier, and add a new, fourth category.

1. Quality Performance: This category reduces the nine measures you now report for PQRS to six. To get a high score, providers have to demonstrate that they've improved their patients' outcomes. This could mean trouble for podiatrists who treat ankle and foot conditions related to chronic illnesses, such as diabetes, arthritis, heart disease, and peripheral arterial disease. Improving health outcomes of related ankle and foot conditions requires regular in-office appointments and patients' compliance with treatment plans, such as the use of exercises, topical creams, etc. Podiatrists may be held responsible for failing to improve health outcomes when their patients are the ones holding up their progress.

2. Resource Use: CMS calculates your score in this category based on your submitted claims; you don't actually have to "report" anything. Resource Use is based on existing VBM methodology, as it aims to keep two of the six current VBM measures and adds 40 new episode-specific measures.

3. Advancing Care Information: This category is focused on information sharing, interoperability, and data security. Here's how the scoring works: You must earn a 50-point base score in order for this category to even count for you. Your performance score and a bonus score will then be added to the base score.

4. Clinical Practice Improvement Activities (new category): Podiatrists who participate in an APM will be partially covered for this category. If you choose MIPS or a commercial equivalent, you'll have to choose at least one activity of the more than 90 activities to avoid a zero. Doing more activities gives you a higher score; and choosing a "high value" activity will give you extra points.

For more details on the MACRA timeline, visit http://www.aafp.org/dam/AAFP/documents/practice_management/payment/MACRATimeline.pdf.