Pulmonology Coding Alert

This guide to MIPS reporting and pulmonology-specific Quality Measures will maximize your 2019 reimbursement bonus

CMS’ Merit-based Incentive Payment System (MIPS) is one of the single largest overhauls to Medicare since its inception, and months after its announcement, many physicians find themselves scratching their heads about how to participate. Or, in some cases, whether they should participate at all.

However, the standards for the 2017 reporting year (which is the 2019 reimbursement year) are fairly easily to meet. Below we discuss what you can do in 2017 to begin meeting and even exceeding the measures for MIPS.

Bonuses are graded on a curve, and many specialties haven’t done their homework

CMS said it anticipates that most eligible clinicians (ECs) will participate in MIPS rather than the Quality Payment Program’s other and more complex value-based reimbursement track, Advanced Alternative Payment Models (APMs). They expect 70,000 to 120,000 qualifying participants (QPs) to choose APMs in 2017. By comparison, the agency said it expects 592,000 to 642,000 ECs to choose MIPS next year, CMS indicated the final rule published Nov. 4, 2016.

A 2016 Deloitte Center for Health Solutions survey shows that 50 percent of the physicians surveyed said they had never heard of MACRA, and another 32 percent said they were familiar with the name but not the requirements, according to the Deloitte report.

Get ready: As pulmonology practice administrators will likely be responsible for ensuring providers and other eligible clinicians are complying with MIPS rules, that’s a red flag.

Note, MIPS does not apply to hospital reimbursement or impact ASC facility fees, CMS clarifies in a Nov. 1, 2016 fact sheet. Eligible clinicians can fulfill MIPS requirements as an individual or as part of a group, and even APM-participating clinicians need to report through MIPS in 2017.

And the bottom line is that it’s inexorable

MIPS is independent of the Affordable Care Act, and so any upheaval from the ACA’s potential repeal will not affect it. MIPS may be a hassle, but it’s inevitable. It will take an act of Congress (literally) to change and you’re required to participate if you want to maintain optimal levels of Medicare reimbursement.

Fortunately, while you’re weighing pros and cons during 2017, you can easily meet the threshold.

And you may be excluded from the participation requirement if:

•  You have Medicare billing charges less than or equal to $30,000 or provide care to 100 or fewer Part B enrolled Medicare beneficiaries in one of the two determination periods

                    ○ 9/1/2015 to 8/31/2016
                    ○ 9/1/2016 to 8/31/2017

• You are a newly Medicare eligible clinician. This includes individual physicians in your practice.
•  You are a qualified APM participant
  ○ Note, even APM participants will need to submit through MIPS in 2017.

Quality measures replace PQRS, will be 60 percent of the 2017 score’s weight

To meet the full requirement for the maximum 60, you must report six measures. One of those must be an outcome measure if possible, which for pulmonology would be:

• Optimal asthma control: Composite measure of the percentage of pediatric and adult patients whose asthma is well-controlled as demonstrated by one of three age appropriate patient reported outcome tools and not at risk for exacerbation

High-priority measures are worth bonus points for the Quality Performance Category, and if you cannot report an outcomes measure then you must report a high-priority measure. Reporting them is optional if you report an outcomes measure. This makes it a smart idea to include as many high-priority measures as possible in your six Quality Performance Category Measures.

“Additional high priority measures are credited up to 5 percent of possible total, and may not impose upon physician work too much,” says Carol Pohlig BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania.

Tip: “If these measures represent something that you are already doing for your patients, you should be able to easily receive credit without an adjustment in your practice flow,” Pohlig says.

Here’s a list of recommended measures:

• Falls: risk assessment
• Falls: plan of care
• Appropriate treatment for children with upper respiratory infection (URI)
• Care plan
• Medication reconciliation post-discharge
• Appropriate testing for children with pharyngitis
• Avoidance of antibiotic treatment in adults with acute bronchitis
• Elder maltreatment screen and follow-up plan
• Documentation of current medications in the medical record
• Pain assessment and follow-up
• Use of high-risk medications in the elderly

If you have not yet selected six measures and are aiming for a positive MIPS Payment Adjustment, select from the other recommended measures.

Reporting at least one measure successfully will qualify for avoiding the MIPS penalty. If you report over six measures, CMS will calculate your MIPS Quality Performance Score using your top performing quality measures.

Take note that the measures must all be reported through the same mechanism, whether it’s EHR, claims reporting, or registry reporting. You can report your quality measures through a qualified clinical data registry (QCDR) like you did with PQRS, CMS explains in a statement on qualified clinical data registry reporting on its site.

Resources: To read the Deloitte study, visit: https://www2.deloitte.com/us/en/pages/life-sciences-and-health-care/articles/macra.html.

The November 2016 MACRA and MIPS final rule can be found here: https://www.federalregister.gov/documents/2016/11/04/2016-25240/medicare-program-merit-based-incentive-payment-system-mips-and-alternative-payment-model-apm.

To read the fact sheet on ASC facility fees, see https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-11-01-3.html.

To learn more about reporting quality measures through the qualified clinical data registry, go to: https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/pqrs/qualified-clinical-data-registry-reporting.html.