Posts Tagged MACRA

New Learning Opportunities Available for County Societies

New Learning Opportunities Available for County Societies

The Medical Association is partnering with Warren Averett in 2019 to provide several topics that you can use to host events that will interest the physician members in your county, at no cost to you. Each talk lasts about 30 minutes and several can be combined for a 60-minute talk.

MACRA/MIPS Refresher. MACRA is now in year three and the law is still changing. This presentation will cover the new areas to address, and what is in the pipeline for years to come.

What Does the New Federal Tax Law Mean to Physicians?  The new tax law affects all taxpayers, but this presentation will center around how the law affects physicians and the items that need to be addressed to minimize your personal tax.

Customer Service in the Medical Practice. Medical practice patients have increasing expectations about their medical care and plenty of options for where to obtain care. The practices where excellence in care is delivered can be selective about which patients to accept and which problem patients to release. The secret to getting highest ratings from patients is often not found in the quality of care you provide. We will share what gets you a 5-star rating and how you can put the processes in place to make raving fans out of your patients and referral sources.

How Can You Increase Employee Morale? Unemployment is at an all-time low, other practices and local employers are bidding at higher pay rates to get your top talent, and younger employees change jobs with greater frequency than older staff. Unless you are willing to pay at the highest wage rate in town, you must cultivate a culture where high morale prevails among your staff. What are the ways other practices are retaining good staff by encouraging fun and a family atmosphere in the workplace?

To book a speaker for your next event, contact Meghan Martin at mmartin@alamedical.org or call (334) 954-2500. CME credit is not provided for these opportunities.  

Posted in: Education

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CMS Releases Proposed Rule for 2019 Medicare Quality Payment Program

CMS Releases Proposed Rule for 2019 Medicare Quality Payment Program

On July 12, the Centers for Medicare & Medicaid Services released its proposed policies for Year 3 (2019) of the Quality Payment Program via the Medicare Physician Fee Schedule Notice of Proposed Rulemaking. The provisions included in the NPRM are reflective of the feedback we received from many stakeholders, and continue to provide additional flexibilities to reduce burden and smooth the transition, where possible, so that doctors and other clinicians can spend more time with patients.

Key proposals for Year 3 of the Quality Payment Program include:

  • Expanding the definition of Merit-based Incentive Payment System (MIPS) eligible clinicians to include new clinician types (physical therapists, occupational therapists, clinical social workers, and clinical psychologists).
  • Adding a third element (Number of Covered Professional Services) to the low-volume threshold determination and providing an opt-in policy that offers eligible clinicians who meet or exceed one or two, but not all, elements of the low-volume threshold the ability to participate in MIPS.
  • Providing the option to use facility-based scoring for facility-based clinicians that don’t require data submission.
  • Modifying the MIPS Promoting Interoperability (formerly Advancing Care Information) performance category to support greater electronic health record (EHR) interoperability and patient access while aligning with the proposed new Promoting Interoperability Program requirements for hospitals.
  • Moving clinicians to a smaller set of Objectives and Measures with scoring based on performance for the Promoting Interoperability performance category.
  • Continuing the small practice bonus, but including it in the Quality performance category score of clinicians in small practices instead of as a standalone bonus.
  • Streamlining the definition of a MIPS comparable measure in both the Advanced Alternative Payment Models (APMs) criteria and Other Payer Advanced APM criteria to reduce confusion and burden amongst payers and eligible clinicians submitting payment arrangement information to CMS.
  • Updating the MIPS APM measure sets that apply for purposes of the APM scoring standard.
  • Increasing flexibility for the All-Payer Combination Option and Other Payer Advanced APMs for non-Medicare payers to participate in the Quality Payment Program.
  • Updating the Advanced APM Certified EHR Technology (CEHRT) threshold so that an Advanced APM must require that at least 75% of eligible clinicians in each APM Entity use CEHRT.
  • Extending the 8% revenue-based nominal amount standard for Advanced APMs through performance year 2024.

Additionally, as a result of our Human-Centered Design research, we’ve included new language that more accurately reflects how clinicians and vendors interact with MIPS. We look forward to your feedback on this approach. Please note that the official commenting mechanisms are outlined below.

Submit Comments by September 10

CMS is seeking comment on a variety of proposals in the NPRM. Comments are due by September 10, 2018.

You must officially submit your comments in one of the following ways:

  • Electronically, through Regulations.gov
  • Regular mail
  • Express or overnight mail
  • By hand or courier

For More Information

To learn more about the PFS NPRM and the Quality Payment Program proposals, review the following resources:

  • Press release – provides more details about the announcement
  • Fact sheet – offers an overview of the proposed policies for 2019 (Year 3) and compares these policies to the current 2018 (Year 2) requirements
  • Webinar – overview of the proposed rule for the 2019 performance period with the opportunity to ask questions

To learn more about the Quality Payment Program, visit: https://qpp.cms.gov.

Posted in: CMS

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CMS Announces New Funding Opportunity for Quality Payment Program (MACRA)

CMS Announces New Funding Opportunity for Quality Payment Program (MACRA)

The Centers for Medicare and Medicaid Services recently announced a new funding opportunity for development, improvement and expansion of quality measures for the Quality Payment Program. According to CMS, the program over three years will provide up to $30 million in funding and technical assistance to clinicians, patients and others working on QPP measures. These cooperative agreements will focus on engagement, data collection to reduce burden, consumer-informed decisions, critical measure gaps and quality measure alignment.

While most physicians are still trying to navigate QPP, the Merit-based Incentive Payment System (MIPS) and the other requirements of MACRA, CMS is beginning to ramp up the implementation of the payment system. Now, physicians need to report on six metrics, which includes one outcome measure from three performance categories: quality, advancing care information and improvement activities. However, beginning in 2019, a fourth category of tying 30 percent of participants’ scores to costs will be added.

There has been disagreement about which quality measures physicians should use, and with over 300 options, the task can be daunting. CMS is hoping more input from stakeholders will lead to better measures that meet program objectives while minimizing administrative workload.

Alabama Quality Assurance Foundation Can Help

The overall goal is to improve patient outcomes and reduce burden by incorporating clinical and patient perspectives in the quality measures development process, but the process has many options and can prove quite daunting. Last year, the Medical Association partnered with the staff at the Alabama Quality Assurance Foundation (AQAF), a nonprofit consulting firm located in Birmingham and contracted by CMS to provide free technical assistance to all Alabama providers. Part of AQAF’s contract with CMS is to provide training to clinicians on the Medicare Access and CHIP Reauthorization Act (MACRA), the Merit-based Incentive Payment System (MIPS) or an Alternative Payment Model (APM).

Technical assistance from the staff at AQAF is always FREE and available immediately by emailing TechAssist@aqaf.com or calling 1-844-205-5540.

Posted in: MACRA

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Bipartisan Budget Act Boosts Health Programs

Bipartisan Budget Act Boosts Health Programs

In a rare show of bipartisanship for the mostly polarized 115th Congress, the Bipartisan Budget Act of 2018 is officially one for the record books. The week leading up to the final vote was far from smooth with Sen. Nancy Pelosi impressively filibustering on the floor of the U.S. Senate for eight hours to Rep. Rand Paul blocking the final vote late Thursday night/early Friday morning and forcing a six-hour government shutdown before allowing the final vote to be taken.

Now that President Trump has signed the Bipartisan Budget Act of 2018 here’s what you need to know:

Technical Amendments to MACRA. Makes several changes to the Medicare Access and CHIP Reauthorization Act (MACRA) that the medical community has been strongly advocating for, including:

  • Excludes Medicare Part B drug costs from MIPS payment adjustments and from the low-volume threshold determination;
  • Eliminates improvement scoring for the cost performance category for the third, fourth and fifth years of MIPS;
  • Allows CMS to reweight the cost performance category to not less than 10 percent for the third, fourth, and fifth years of MIPS;
  • Requires CMS to update on CMS’ website by Dec. 31 of each year, information on resource use measures including measures under development, the time-frame for such development, potential future resource use measure topics, a description of stakeholder engagement and the percent of expenditures under Medicare Part A and B that are covered by resource use measures.
  • Allows CMS flexibility in setting the performance threshold for years three through five to ensure a gradual and incremental transition to the performance threshold set at the mean or median for the sixth year;
  • Allows the Physician Focused Payment Model Technical Advisory Committee (PTAC) to provide initial feedback regarding the extent to which models meet criteria and an explanation of the basis for the feedback.

Physician fee schedule update (in lieu of Misvalued Codes). Reduces the Physician Fee Schedule conversion factor for 2019 from 0.5 percent to 0.25 percent. This is more favorable language than, and is in lieu of, the language in the House bill that would extend the “misvalued codes” provision for one additional year. The AMA estimated, based on the recommendations of the AMA / Specialty Society Relative Value Scale Update Committee (RUC), that the misvalued code provision in the House bill would have reduced the statutory 0.5 percent payment update in 2019 by 0.45 percent. Rejection of the misvalued code policy is an important outcome for future budget saving exercises. On a bipartisan basis, policymakers have recognized that the misvalued code “budget dial” is tapped out and should be shelved.

IPAB. Permanently repeals the Independent Payment Advisory Board. IPAB was a 15-member government agency created in 2010 by the Affordable Care Act for achieving specified savings in Medicare without affecting coverage or quality.

Children’s Health Insurance Program (CHIP). CHIP is extended for an additional four years beyond the previous Continuing Resolution’s six-year extension, with appropriations made through 2027.

Community Health Centers. Funding for community health centers is reauthorized for two years at a level of $3.8 billion for FY 2018 and $4 billion for FY 2019.

Medicare payment cap for therapy services. Permanently repeals the outpatient therapy caps beginning on Jan. 1, 2018.

National Health Service Corps. Funding for the National Health Service Corps is extended at the FY 2015 – 2017 annual level of $310 million for two additional years.

Teaching Health Center Graduate Medical Education. Funding for Teaching Health Center Graduate Medical Education is extended for two years at an annual level of $126.5 million, more than doubling annual funding for this program.

Geographic Practice Cost Indices (GPCI) floor. Extends the work GPCI floor for two additional years through Jan. 1, 2020.

Reducing EHR Significant Hardship. Removes the current mandate that meaningful use standards become more stringent over time. This eases the burden on physicians as they would no longer have to submit and receive a hardship exception from HHS.

Closing the Donut Hole for Seniors. Closes the Medicare Part D prescription drug “donut hole” sooner than under current law by increasing the discounted price manufacturers provide from 50 percent to 70 percent.

Emergency Medicaid Funds for Puerto Rico and the U.S. Virgin Islands. Puerto Rico’s Medicaid caps for 2018 – 2019 are increased by an additional $4.8 billion. The Virgin Islands’ caps are increased over the same time period by $142.5 million. Also, 100 percent federal cost sharing for Medicaid is provided for both territories through Sept. 30, 2019.

Prevention and Public Health Fund (PPHF). The Senate bill reduces funding for the PPHF by $1.35 billion between FY 2018 – 2027.

Other Select Budget Agreement Provisions:

Note: there is an agreement to include these funds in the Omnibus before the March 23 deadline.

  • $6 billion in funding for the opioid crisis and for mental health
  • $4 billion to rebuild and improve VA Hospitals and clinics
  • $2 billion for NIH research (above CURES Act increases)

Click here if you would like to see how Alabama’s Congressional Delegation voted.

Posted in: Advocacy

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Updates to 2017 Extreme and Uncontrollable Circumstances Policy for MIPS Clinicians

Updates to 2017 Extreme and Uncontrollable Circumstances Policy for MIPS Clinicians

The Centers for Medicare & Medicaid Services has updated its Extreme and Uncontrollable Circumstances policy for the 2017 Merit-based Incentive Payment System (MIPS) transition year to include counties affected by Hurricane Nate and additional counties affected by the California wildfires. CMS understands that living in an area where these disasters took place may impact your resources to collect or submit data on time.

The data submission period for the 2017 transition year of MIPS is January 2- March 31, 2018. MIPS eligible clinicians in Federal Emergency Management Agency (FEMA) designated areas affected by Northern California wildfires and Hurricanes Harvey, Irma, Maria and Nate will be automatically identified. No action is required. However, if you are automatically identified but still choose to submit data on two or more MIPS performance categories (either as an individual or group), you’ll be scored on those performance categories and your MIPS payment adjustment will be based on your final score.

MIPS eligible clinicians in these newly identified designated areas for Hurricane Nate and the California Wildfires are now covered by the Extreme and Uncontrollable Circumstances policy:

  • Alabama: Autauga, Baldwin, Choctaw, Clarke, Dallas, Macon, Mobile, and Washington
  • Mississippi: George, Greene, Hancock, Harrison, Jackson, and Stone
  • California: Butte, Lake, Mendocino, Napa, Nevada, Orange, Santa Barbara, Solano, Sonoma, Ventura, and Yuba

To learn more about the policy and all the designated areas for the 2017 transition year, view the interim final rule with comment period and the Extreme and Uncontrollable Circumstances Policy for MIPS in 2017 Fact Sheet.

Questions? The Quality Payment Program Service Center can be reached at 1-866-288-8292 (TTY 1-877- 715- 6222), Monday through Friday, 8:00 AM-8:00 PM Eastern time or by email at: QPP@cms.hhs.gov.

Posted in: CMS

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MACRA: Rolled Out and Still Rolling

MACRA: Rolled Out and Still Rolling

Most physicians have, by this point, gained some familiarity with the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The name of this law has appeared frequently in commentary over the past several years, and the changes it imposes are well on their way. However, many of the details concerning MACRA’s implementation—how it affects physicians on the ground and what they need to do on a practical and technical level in order to comply with its requirements—deserve additional attention. It is, after all, a law that changes much about the Medicare payment landscape, and new guidance from the government continues to appear.

This article will discuss three recent releases from the Centers for Medicare & Medicaid Services (CMS) that concern MACRA, dating from the end of 2017 through the beginning of 2018. There is obviously much more that physicians should note about MACRA as we head further into 2018, but hopefully, this very brief article can serve as a springboard into the many features of this multifaceted new legal scheme.

  1. Starting with the most recent news release, on Jan. 3, 2018, of this year CMS announced that it had launched a new system for clinicians in the Quality Payment Program to submit their 2017 performance data. This system is located on the Quality Payment Program website, and because it replaces an array of former systems on multiple websites, it should make such data submission easier. For most clinicians, the 2017 submission period runs from Jan. 2, 2018, to March 31, 2018. Therefore, exploring this website’s new system for submission — including developing familiarity with the log-in and submission procedures — sooner rather than later is advisable. There are multiple data submission options embedded in the website, and thus having some advance knowledge of the preferred method should benefit a clinician. Eligible clinicians will see in real time the initial scoring, which may later change, for each of the Merit-based Incentive Payment System (MIPS) performance categories as they submit their data. CMS’ news release included a link to a fact sheet on this new system, which can be accessed here.
  2. On Dec. 19, 2017, CMS published the “2018 Medicare Electronic Health Record (EHR) Incentive Program Payment Adjustment Fact Sheet for Eligible Clinicians.” The referenced Payment Adjustment relates to the reduced Medicare payments for clinicians who do not demonstrate that they are meaningful users of Certified Electronic Health Record (EHR) Technology. This year is the final year of meaningful-use payment adjustments under the Medicare EHR Incentive Program, but the need to meet EHR standards is not going away: MACRA combines certain aspects of this Medicare EHR Incentive Program with other programs into MIPS, and the basic requirements that established meaningful use will still factor in as a percentage of a clinician’s MIPS score. The MIPS payment adjustments will be applied to Medicare Part B payments in 2019 for the 2017 performance period. CMS’ news release containing additional details can be accessed here.
  3. On Nov. 2, 2017, CMS issued a rule containing updates to the payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule for this year. This is not a MACRA-specific rule; instead, it demonstrates how MACRA has already become incorporated into the Medicare payment landscape as a whole. For example, MACRA helped determine the overall update to payments under the Fee Schedule, which is +0.41 percent for this year; the rule discusses the replacement of the Physician Quality Reporting System by MIPS; the rule also discusses the patient relationship code categories required under MACRA. In short, MACRA’s impact on the payment landscape is varied and pervasive. The time for getting up to speed on the practical implementation of this law has certainly arrived.

As noted above, MACRA is here among us, and it touches upon many facets of a physician’s practice. In order to avoid the various causes of decreased reimbursement, it benefits physicians to proactively seek to understand the ongoing requirements ushered in by the law.

Article contributed by Chris Thompson, an attorney at Burr & Forman LLP practicing within the firm’s Health Care Industry Group. Burr & Forman LLP is an official partner with the Medical Association.

Posted in: Legal Watch

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Medical Association’s 2018 State and Federal Agendas

Medical Association’s 2018 State and Federal Agendas

The Medical Association Board of Censors has met and approved the Association’s 2018 State and Federal Agendas. These agendas were developed with guidance from the House of Delegates and input from individual physicians. As the Alabama Legislature and U.S. Congress begin their work for 2018, additional items affecting physicians, medical practices and patients may be added to this list.

Download the Medical Association’s 2018 State and Federal Agendas (PDF)

 

2018 STATE AGENDA

 

The Medical Association supports:

  • Ensuring legislation “first do[es] no harm”
  • Extending the Medicaid payment bump for primary care to all specialties of medicine
  • Eliminating the health insurance-coverage gap for the working poor
  • Ensuring fair payment for patient care and reducing administrative burdens on physicians and medical practices
  • Strengthening existing tort reforms and ensuring liability system stability
  • Empowering patients and their doctors in making medical decisions
  • Continued physician compounding, dispensing of drugs
  • The same standards and reimbursements for telehealth and face-to-face visits
  • Training, education and licensing transparency of all individuals involved in patient care
  • Continued self-regulation of medicine over all areas of patient care
  • Increased state funding to upgrade the Prescription Drug Monitoring Program to a useful tool for physician monitoring patients at risk for drug interactions and overdose potential
  • Using data analytics to combat the drug abuse epidemic by strengthening research capabilities of pre-approved, de-identified prescription information
  • Maintaining the Alabama Department of Public Health as the repository for PDMP information to ensure continuity for prescribers and dispensers and security for patients
  • Standard opioid education in medical school so the physicians of tomorrow are prepared to face the realities and responsibilities of opioid prescribing

 

The Medical Association opposes:

  • The radical Patient Compensation System legislation
  • Legislation/initiatives increasing lawsuits against physicians
  • Non-physicians setting standards for medical care delivery
  • Tax increases disproportionately affecting physicians
  • Expanding access to the Prescription Drug Monitoring Program (PDMP) for law enforcement
  • Statutory requirements for mandatory PDMP checks
  • Further expansion of Maintenance of Certification (MOC) requirements
  • Changes to workers’ compensation laws negatively affecting treatment of injured workers and medical practices
  • Any scope of practice expansions that endanger patients or reduces quality of care
  • Biologic substitution legislation that allows lower standards in Alabama than those set by the FDA that doesn’t provide immediate notifications to patients and their physicians when a biologic is substituted, and that increases administrative burdens on physicians and medical practices

 

2018 FEDERAL AGENDA

 

The Medical Association supports:

  • Meaningful tort reforms that maintain existing state protections
  • Reducing administrative and regulatory burdens on physicians and medical practices
  • Repeal of the Affordable Care Act and replacement with a system that:
    • Includes meaningful tort reforms that maintain existing state protections
    • Preserves employer-based health insurance
    • Protects coverage for patients with pre-existing conditions
    • Protects coverage for dependents under age 26
    • With proper oversight, allows the sale of health insurance across state lines
    • Allows for deducting individual health insurance expenses on tax returns
    • Increases allowed contributions to health savings accounts
    • Ensures access for vulnerable populations
    • Ensures universal, catastrophic coverage
    • Does not increase uncompensated care
    • Does not require adherence with insurance requirements until insurance reimbursement begins
    • Reduces administrative and regulatory burdens
  • Overhauling federal fraud and abuse programs
  • Reforming the RAC program
  • Prescription drug abuse education, prevention and treatment initiatives
  • Allowing patient private contracting in Medicare
  • Expanding veterans’ access to non-VA physicians
  • Reducing escalating prescription drug costs
  • A patient-centered MACRA framework, including non-punitive and flexible implementation of new MIPS, PQRS and MU requirements
  • Congressional reauthorization of CHIP (Children’s Health Insurance Program) at the current enhanced funding level
  • Better interstate PDMP connectivity
  • Eliminating “pain” as the fifth vital sign
  • Repealing the “language interpreters” rule
  • Requiring all VA facilities, methadone clinics and suboxone clinics to input prescription data into state PDMPs where they are located

 

The Medical Association opposes:

  • Non-physicians setting standards for medical care delivery
  • Publication of Medicare physician payment data
  • National medical licensure that supersedes state licensure
  • Legislation/initiatives increasing lawsuits against physicians

Posted in: Advocacy

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CMS Issues Final Rule on 2018 Medicare Reimbursement

CMS Issues Final Rule on 2018 Medicare Reimbursement

The Centers for Medicare & Medicaid Services has issued a final rule that includes updates to payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after Jan. 1, 2018.

Background on the Physician Fee Schedule

Payment is made under the PFS for services furnished by physicians and other practitioners in all sites of service. These services include but are not limited to, visits, surgical procedures, diagnostic tests, therapy services and specified preventive services.

In addition to physicians, payment is made under the PFS to a variety of practitioners and entities, including nurse practitioners, physician assistants, and physical therapists, as well as radiation therapy centers and independent diagnostic testing facilities.

Payments are based on the relative resources typically used to furnish the service. Relative Value Units (RVUs) are applied to each service for work, practice expense, and malpractice. These RVUs become payment rates through the application of a conversion factor. Payment rates are calculated to include an overall payment update specified by statute.

Patients Over Paperwork

CMS recently launched the “Patients Over Paperwork” Initiative, a cross-cutting, collaborative process that evaluates and streamlines regulations with a goal to reduce unnecessary burden, increase efficiencies, and improve the beneficiary experience. This effort emphasizes a commitment to removing regulatory obstacles that get in the way of providers spending time with patients. The Medicare Physician Fee Schedule final rule includes the following as part of this initiative:

  • reducing reporting requirements
  • removing downward payment adjustments based on performance for practices that meet minimum quality reporting requirements 

Payment Provisions 

Changes in Valuation for Specific Services

CMS reviews the resource inputs for several hundred codes under the annual process referred to as the potentially misvalued code initiative. Recommendations from the American Medical Association-Relative Value Scale Update Committee (RUC) are critically important to this work. For CY 2018, CMS is finalizing the values for individual services that generally reflect the expert recommendations from the RUC without as many refinements as CMS made in recent years.

Overall Payment Update and Misvalued Code Target

The overall update to payments under the PFS based on the finalized CY 2018 rates will be +0.41 percent. This update reflects the +0.50 percent update established under the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, reduced by 0.09 percent, due to the misvalued code target recapture amount, required under the Achieving a Better Life Experience (ABLE) Act of 2014.

After applying these adjustments, and the budget neutrality adjustment to account for changes in RVUs, all required by law, the final 2018 PFS conversion factor is $35.99, an increase to the 2017 PFS conversion factor of $35.89.

Payment Rates for Nonexcepted Off-campus Provider-Based Hospital Departments Paid Under the PFS

Section 603 of the Bipartisan Budget Act of 2015 requires that certain items and services furnished by certain off-campus hospital outpatient provider-based departments are no longer paid under the OPPS beginning Jan. 1, 2017. For CY 2017, CMS finalized the PFS as the applicable payment system for most of these items and services.

For CY 2018, CMS is finalizing a reduction to the current PFS payment rates for these items and services by 20 percent. CMS currently pays for these services under the PFS based on a percentage of the OPPS payment rate. Specifically, the final policy will change the PFS payment rates for these services from 50 percent of the OPPS payment rate to 40 percent of the OPPS rate. CMS believes this adjustment will provide a more level playing field for competition between hospitals and physician practices by promoting greater payment alignment.

Medicare Telehealth Services

For CY 2018, CMS is finalizing the addition of several codes to the list of telehealth services, including:

  • HCPCS code G0296 (visit to determine low dose computed tomography (LDCT) eligibility);
  • CPT code 90785 (Interactive Complexity);
  • CPT codes 96160 and 96161 (Health Risk Assessment);
  • HCPCS code G0506 (Care Planning for Chronic Care Management); and
  • CPT codes 90839 and 90840 (Psychotherapy for Crisis).

CMS is finalizing its proposal to eliminate the required reporting of the telehealth modifier GT for professional claims in an effort to reduce administrative burden for practitioners and finalizing separate payment for CPT code 99091, which describes certain remote patient monitoring, for CY 2018.

In the proposed rule, CMS sought comment on whether to make separate payment for CPT codes that describe remote patient monitoring or other existing codes that describe extensive use of communications technology. Some commenters raised concerns with our proposal, citing concerns that existing CPT codes were overly broad and not always reflective of current technology. Other commenters were supportive of the proposal generally but noted that CPT is currently working on codes that more accurately describe remote patient monitoring. In the final rule, CMS is finalizing separate payment for CPT code 99091 (Collection and interpretation of physiologic data (e.g., ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional, qualified by education, training, licensure/regulation (when applicable) requiring a minimum of 30 minutes of time, for 2018 pending anticipated changes in CPT coding.

Malpractice Relative Value Units (RVUs)

For CY 2017, CMS collected updated professional liability insurance data for the purposes of updating the malpractice geographic practice cost indices but did not propose to use the data to update the specialty risk factors used in the calculation of malpractice RVUs at that time. Rather, CMS solicited comment on whether it should consider updating the malpractice RVUs based on the updated professional liability insurance data prior to the next expected 5-year update (CY 2020).

After consideration of public comments received, for CY 2018, CMS is not finalizing its proposal to develop malpractice RVUs using the most recent data available. Implementation not finalizing the proposal to use premium data collected for the would occur by CY 2017 malpractice geographic practice cost indices to update the specialty risk factors for CY 2018-2020. Additionally, CMS is not finalizing the proposal to align the update of malpractice premium data with the malpractice geographic practice cost index updates, which has been done once every three years, at this time.

Care Management Services

CMS is continuing efforts to improve payment within traditional fee-for-service Medicare for chronic care management and similar care management services to accommodate the changing needs of the Medicare patient population. CMS is finalizing its proposals to adopt CPT codes for CY 2018 for reporting several care management services currently reported using Medicare G-codes and clarifying a few policies regarding chronic care management in this final rule.

Improvement of Payment Rates for Office-based Behavioral Health Services

CMS is finalizing an improvement in the way physician fee schedule rates are set that will positively impact office-based behavioral health services with a patient. The final policy will increase payment for these important services by better recognizing overhead expenses for office-based face-to-face services with a patient.

Evaluation and Management Comment Solicitation

Most physicians and other practitioners bill patient visits to the PFS under a relatively generic set of codes that distinguish level of complexity, site of care, and in some cases whether or not the patient is new or established, or Evaluation and Management (E/M) visit codes. Billing practitioners must maintain information in the medical record that documents they have reported the appropriate level of E/M visit code. CMS maintains guidelines that specify the kind of information that is required to support Medicare payment for each level.

CMS agreed with continued feedback from stakeholders that these guidelines are potentially outdated and need to be revised.

CMS thanks the public for the comments received in response to the proposed rule’s comment solicitation on the E/M guidelines and summarizes these comments in the final rule. Commenters suggested additional avenues for collaboration with stakeholders prior to implementing any changes, and CMS will consider the best approaches for such collaboration and will take the public comments into account for future rulemaking.

Emergency Department Visits Comment Solicitation

CMS sought comment from stakeholders on whether emergency department visits are undervalued due to increasing heterogeneity of the settings under which emergency department visits are furnished and changes to the patient population. A number of comments were received suggesting these services are potentially misvalued and will be reviewing emergency department visits (CPT codes 99281-99385) as potentially misvalued for future rulemaking.

Solicitation of Public Comments on Initial Data Collection and Reporting Periods for Clinical Laboratory Fee Schedule

The Clinical Laboratory Fee Schedule (CLFS) final rule entitled “Medicare Program: Medicare Clinical Diagnostic Laboratory Tests Payment System” implements Section 1834A of the Social Security Act (the Act), which requires extensive revisions to the Medicare payment, coding, and coverage for Clinical Diagnostic Laboratory Tests (CDLTs) paid under the CLFS. Under the final rule, the payment amount for a test on the CLFS furnished on or after Jan. 1, 2018, generally will be equal to the weighted median of private payer rates determined for the test, based on the data of applicable laboratories that is collected during a specified data collection period and reported to CMS during a specified data reporting period. The first data collection period was from Jan. 1 through June 30, 2016, and the first data reporting period was from Jan. 1, 2017, through March 31, 2017.

Laboratory industry feedback suggested that many reporting entities would not be able to submit a complete set of applicable information to CMS by the March 31, 2017, deadline. As a result, on March 30, 2017, CMS announced a 60-day period of enforcement discretion until May 30, 2017, with respect to the data reporting period for reporting applicable information under the Medicare CLFS and the application of the Secretary’s potential assessment of civil monetary penalties (CMPs) for failure to report applicable information.

In the proposed rule, CMS solicited public comments from applicable laboratories and reporting entities to better understand applicable laboratories’ experiences with the data reporting, data collection, and other compliance requirements for the first data collection and reporting periods under the new private payor rate-based CLFS.

Part B Drugs: Payment for Biosimilar Biological Products

In the CY 2016 PFS final rule with comment period, CMS finalized a proposal to make clear that biosimilar products that rely on a common reference product’s biologics license application are grouped into the same payment calculation for determining a single average sales price payment limit, and that a single Healthcare Common Procedure Coding System (HCPCS) code is used for such biosimilar products.

In the CY 2018 PFS proposed rule, CMS asked for comments on the effects of its payment policy based on experience with the United States’ biosimilar product marketplace.

CMS received numerous comments on this issue. In response to concerns raised in the comments, CMS is changing the policy to separately code and pay for biological biosimilar products under Medicare Part B. Effective Jan. 1, 2018, newly approved biosimilar biological products with a common reference product will no longer be grouped into the same billing code.

CMS believes a solution that increases provider and patient choice is superior to existing policy and may lead to additional cost savings over the long-term. By encouraging innovation and greater manufacturer participation in the marketplace, this policy change will result in the licensing of more biosimilar products, creating a stable and robust market, driving competition and decreasing uncertainty about access and payment. Carrying out this policy change as early as possible, rather than waiting, is expected to bring more certainty to the new and developing marketplace.

Part B Drug Payment: Infusion Drugs Furnished through an Item of Durable Medical Equipment (DME)

The 21st Century Cures Act transitioned payment for infusion drugs or biologicals furnished through a covered item of DME from average wholesale price (AWP) to average sales price (ASP) pricing methodology on Jan. 1, 2017. CMS is finalizing the proposed revision to 42 CFR §414.904(e)(2) to conform regulations with the statutory payment requirements in section 5004(a) of the 21st Century Cures Act.

New Care Coordination Services and Payment for Rural Health Clinics (RHCs) and Federally-Qualified Health Centers (FQHCs)

CMS is finalizing the proposal to revise payment for chronic care management in RHCs and FQHCs, and establish requirements and payment for RHCs and FQHCs furnishing general behavioral health integration (BHI) services and psychiatric collaborative care model (CoCM) services. Effective Jan. 1, 2018, RHCs and FQHCs will be paid for CCM, general BHI, and psychiatric CoCM using two new billing codes created exclusively for RHC and FQHC payment. This payment would be in addition to the payment for an RHC or FQHC visit.

Appropriate Use Criteria for Advanced Diagnostic Imaging

CMS is finalizing a start date for the Medicare Appropriate Use Criteria (AUC) Program for Advanced Diagnostic Imaging. The program will begin in a manner that allows practitioners more time to focus on and adjust to the Quality Payment Program before being required to participate in the AUC program. The Medicare AUC program will begin with an educational and operations testing year in 2020, which means physicians would be required to start using AUCs and reporting this information on their claims. During this first year, CMS is proposing to pay claims for advanced diagnostic imaging services regardless of whether they correctly contain information on the required AUC consultation. This allows both clinicians and the agency to prepare for this new program.

CMS posted newly qualified provider-led entities and clinical decision support mechanisms in July of this year. Qualified provider-led entities are permitted to develop AUC, and qualified clinical decision support mechanisms are the tools that physicians use to access the AUC. Physicians may begin exploring these mechanisms well in advance of the start of the Medicare AUC program through the voluntary participation period that will begin mid-2018 and run through 2019. During this time CMS will collect limited information on Medicare claims to identify advanced imaging services for which consultation with appropriate use criteria took place.

In addition, by having qualified clinical decision support mechanisms available (some of which are free of charge) clinicians may use one of these mechanisms to earn credit under the Merit-Based Incentive Payment System as an improvement activity. This improvement activity was included in the 2018 Quality Payment Program final rule.

Medicare Diabetes Prevention Program Expanded Model

The final rule also implements the Medicare Diabetes Prevention Program (MDPP) expanded model starting in 2018. The MDPP expanded model was announced in early 2016, when it was determined that the Diabetes Prevention Program (DPP) model test through the Center for Medicare and Medicaid Innovation’s Health Care Innovation Awards met the statutory criteria for expansion. The final rule includes additional policies necessary for suppliers to begin furnishing MDPP services nationally in 2018, including the MDPP payment structure, as well as additional supplier enrollment requirements and supplier compliance standards aimed to enhance program integrity.

Physician Quality Reporting System (PQRS)

Under the PQRS, individual eligible professionals and group practices who did not satisfactorily report data on quality measures for the CY 2016 reporting period are subject to a downward payment adjustment of 2.0 percent in 2018 to their PFS covered professional services. 2016 was the last reporting period for PQRS. The final data submission timeframe for reporting 2016 PQRS quality data to avoid the 2018 PQRS downward payment adjustment was January through March 2017. PQRS is being replaced by the Merit-based Incentive Payment System (MIPS) under the Quality Payment Program (QPP). The first MIPS performance period is January through December 2017.

CMS proposed and is finalizing a change to the current PQRS program policy that requires reporting of nine measures across three National Quality Strategy domains to only require reporting of six measures for the PQRS with no domain requirement. We are also finalizing similar changes to the clinical quality measure reporting requirements under the Medicare Electronic Health Record Incentive Program for eligible professionals who reported electronically through the PQRS portal.

We finalized these changes based on stakeholder feedback and to better align with the MIPS data submission requirements for the quality performance category. For MIPS, eligible clinicians need only report six quality measures for the quality performance category, except those reporting via the Web Interface, and there is no requirement to ensure that the measures span across three National Quality Strategy domains.

Patient Relationship Codes

In May 2017, CMS posted the operational list of patient relationship categories that are required under section 101(f) of MACRA. In this rule, we finalized certain Level II HCPCS modifiers to be used on claims to indicate these patient relationship categories. Further, we finalized a policy that the reporting of these HCPCS modifiers may be voluntarily by clinicians associated with these patient relationship categories beginning Jan. 1, 2018. We anticipate that there will be a learning curve with respect to the use of these modifiers, and we will work with clinicians to ensure their proper use.

Medicare Shared Savings Program

CMS is finalizing several modifications to the rules for accountable care organizations (ACOs) participating in the Medicare Shared Savings Program. These modifications are designed to reduce burden and streamline program operations. The new policies include the following:

  • Revisions to the assignment methodology for ACOs that include FQHCs and RHCs by eliminating the requirement to enumerate each physician working in the FQHC or RHC on the ACO participant list;
  • Reduction of burden for ACOs submitting an initial Shared Savings Program application or the application for use of the skilled nursing facility (SNF) Three-Day Rule Waiver; and
  • The addition of three new chronic care management codes (CCM) and four behavioral health integration (BHI) codes to the definition of primary care services used in the ACO assignment methodology.

2018 Value Modifier

In order to better align incentives and provide a smoother transition to the new Merit-based Incentive Payment System under the Quality Payment Program, we are finalizing the following changes to previously-finalized policies for the 2018 Value Modifier:

  • Reducing the automatic downward payment adjustment for not meeting the criteria to avoid the PQRS adjustment from negative four percent to negative two percent (-2.0 percent) for groups of ten or more clinicians; and from negative two percent to negative one percent (-1.0 percent) for physician and non-physician solo practitioners and groups of two to nine clinicians;
  • Holding harmless all physician groups and solo practitioners who met the criteria to avoid the PQRS adjustment from downward payment adjustments for performance under quality-tiering for the last year of the program; and
  • Aligning the maximum upward adjustment amount to 2 times the adjustment factor for all physician groups and solo practitioners.
  • Given final policy changes for the Physician Quality Reporting System and the Value Modifier, we finalized that we will not report 2018 Value Modifier data in the Physician Compare downloadable database as this would be the first and only year such data would have been reported. However, to promote transparency we will continue to make available the Value Modifier public use and research identifiable files.

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CMS Cancels Some Bundled Payment Proposals

CMS Cancels Some Bundled Payment Proposals

CMS released a proposed rule that reduced the number of mandatory geographic areas for the joint bundled payment program and cancels the cardiac bundled payment program model.

In response to the cut, the American College of Cardiology released a statement indicating the ACC “will continue to work with CMS on opportunities for clinicians to participate meaningfully in Advanced Alternative Payment Models. As we move from volume-based care to value-based care, the path forward is challenging and we must work together to find solutions.”

The cardiac bundled program was set to begin in January 2018, but the bundled payment programs have been delayed multiple times. By eliminating the bundling programs, CMS also removes one of the ways providers can qualify for MACRA’s 5 percent advanced payment model bonus.

“Changing the scope of these models allows CMS to test and evaluate improvements in care processes that will improve quality, reduce costs, and ease burdens on hospitals,” said CMS Administrator Seema Verma. “Stakeholders have asked for more input on the design of these models. These changes make this possible and give CMS maximum flexibility to test other episode-based models that will bring about innovation and provide better care for Medicare beneficiaries.”

Moving forward, CMS expects to increase opportunities for providers to participate in voluntary initiatives rather than large mandatory episode payment model efforts, including additional voluntary episode-based payment models, the agency said.

The episode payment models and the cardiac rehab incentive models were designed as mandatory payment models to test the effects of bundling cardiac and orthopedic care beginning in 2018.

Read the proposed rule here

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Physicians Can Now Apply for Hardship Exception for QPP

Physicians Can Now Apply for Hardship Exception for QPP

Physicians who have insufficient internet connectivity, “extreme and uncontrollable” circumstances or lack of control over the availability of certified electronic health record technology can begin applying for a hardship exception from the Quality Payment Program (QPP) requirement. The exception is for physicians eligible to participate in the Merit-based Incentive Payment System (MIPS). Hospital-based physicians are considered

Hospital-based physicians are considered special status and do not need to apply for a 2017 hardship exception.

 

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Posted in: MACRA

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