Primary Care Coding Alert

CMS presents ‘pick your pace’ options for 2017.

If you have been thinking about the Medicare Access and CHIP Reauthorization Act (MACRA) and what you need to do to satisfy its requirements, the Centers for Medicare & Medicaid Services (CMS) provides some guidance in this regard. Now’s the time to learn what MACRA has in store and whether or not you benefit by adopting MACRA early in your practice.

Background: The final MACRA rule removes the threat of Sustainable Growth Rate cuts, and it holds promise for physicians who give high regard to providing quality care. MACRA has consolidated previously used quality reporting programs and has created the Quality Payment Program (QPP), which includes two new payment tracks, namely, the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (AAPMs).

These two payment tracks provide practices with a number of options for entry and reporting, which aim to incentivize performance, patient engagement, and coordination of care, assisting providers both professionally and financially with their delivery of care.

But, with new changes come the possibility of new challenges. And one challenge that practitioners face is whether to enter into the system or face penalties as they did with Meaningful Use (MU) and PQRS (Physician Quality Reporting System). Consider what you will need to do under the new payment system and whether it is a good option to adopt into it at the earliest opportunity before making your decision.

Know What MIPS has in Store

MIPS will combine PQRS, MU, and the Value based Payment Modifier (VBPM). Under MIPS, you will have four performance categories: quality (which replaces the PQRS), cost (which replaces the VBPM), advancing care information (ACI) (which replaces the Medicare electronic health record (EHR) Incentive program or MU), and a fourth, new category called Improvement Activities (IA).

To fully participate in the MIPS Quality category as an individual, your clinician must choose six measures to report versus the nine measures previously required under PQRS. These six measures will include an outcome measures and reporting is for a minimum of 90 days. If you are submitting data as a group, you may need to report more measures for a full year.

For the cost category, you will not need to submit any data additionally. CMS will collect the data from adjusted Medicare claims.

Advancing Care Information (ACI) is comprised of a base score (50%) and performance score (50%). “Physicians must report all required measures to receive a base score, and failure to achieve a base score will result in a score of zero for the entire performance category,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. Required measures will vary depending on which version of certified EHR technology you are using. If you have technology certified to the 2015 edition or a combination of technologies from 2014 and 2015 editions that support the measures, you can use the ACI objectives and measures, which include the following required measures:

• Security analysis
• e-Prescribing
• Provide patient access
• Send summary of care
• Request/accept summary of care.

You need to submit additional measures for a minimum duration of 90 days to receive additional credit. In addition, CMS specifies that you can receive bonus credit if you:

• Report public health and Clinical Data Registry reporting measures
• Use certified EHR technology to complete some improvement activities listed in the newly created IA payment category.

For the IA category, the focus is on care coordination, beneficiary engagement, and patient safety. Clinicians have to select from a list of more than 90 options among nine categories and attest to performing. You need to attest that you have completed up to two high weighted or four medium weighted improvement activities (or a combination of the two to get a total of 40 points) for a minimum duration of 90 days to get complete credit.

Your scores from all four categories is consolidated to get a final score between zero and one hundred (0-100). This score is then compared with all other eligible clinicians’ scores and against a performance threshold to determine your physician’s payment adjustment under the Medicare physician fee schedule.

“Note that CMS does not weight the four categories equally,” Moore says. “In 2017, quality is 60% of the final score, and cost is 0%; ACI and IA are 25% and 15%, respectively.”

Know Whether You Need to Adopt MIPS Early

Since the system is new, you might feel a little overwhelmed with adopting MIPS immediately into your practice. But, before you think of opting out, you should know if you benefit if you take on MIPS early in your practice. When you look at the requirements listed out for 2017, you see that it is not only easier you might also enjoy the benefit of getting a bonus.

However, you should be aware that MIPS has upside and downside risk starting at as much as four percent in 2019 and increasing to as much as nine percent by 2022. MIPS is budget-neutral and graded on a curve, so you should remember there will be winners and losers, depending upon your peers’ performance.

Caveat: Don’t forget MIPS does have four distinct categories that cover criteria that must be met in order to receive that coveted incentive.

Benefit from CMS’ ‘Pick Your Pace’ Options for 2017

For the transitional year 2017, CMS has established four paths providers who are not in AAPMs may follow, each with the minimum performance threshold. The four paths are:

Non-participation:  Not participating in MIPS by not sending in any 2017 data will earn you a four percent negative payment adjustment in 2019.

Minimal Participation (also known as the Test option): If you submit a minimum amount of 2017 data to Medicare (for example, one quality measure or one improvement activity or the required ACI measures), you can avoid a downward payment adjustment in 2019.

Partial Participation: If you submit at least 90 days of 2017 data to Medicare for more than one quality measure, or more than one improvement activity, or more than the required ACI measures, you may earn a neutral or small positive payment adjustment in 2019.

Full Participation: If you submit at least 90 days and up to a full year of 2017 data to Medicare for all required quality measures, and all required improvement activities, and all required ACI measures, you may earn a small or moderate positive payment adjustment.

Providers will be graded using four quartiles above and below the performance threshold. Your position in the quartile will determine whether you get the maximum penalty or the maximum bonus in the target year. MACRA allows a potential three times upward adjustment for the highest performers, but achieving that is unlikely. Those in the exceptional bonus pool could qualify for additional bonus money from a separate $500 million dollar pool.

“With ‘Pick Your Pace,’ CMS has set the bar pretty low for 2017,” notes Moore. “As noted, it only takes one quality measure or one improvement activity to avoid a 4% cut in Medicare payments in 2019.”

Resources: For more information, visit at https://qpp.cms.gov/