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Evaluating and Managing the E/M Codes for 2019 and Beyond

Evaluating and Managing the E/M Codes for 2019 and Beyond

Editor’s Note: This article is the first in a series of articles about notable changes in the 2019 Physician Fee Schedule Final Rule.

In the 2019 Physician Fee Schedule (“PFS”) Proposed Rule, the Centers for Medicare and Medicaid Services (“CMS”) proposed some major changes to the PFS, including changes to the way Evaluation and Management (“E/M”) services are reimbursed. The PFS Final Rule[1] contains some good news and bad news. The good news . . . CMS isn’t making any of the major changes it proposed in 2019. The bad news . . . they plan on making some big changes over the next few years.

<<Quick Summary: 2019 Medicare Physician Fee Schedule and Quality Payment Program Final Rule>>

Proposal

CMS proposed to collapse several levels of E/M Codes into one reimbursement level with add-on codes for certain prolonged or complex visits.

Final Rule

CMS is reducing some documentation redundancies for 2019, but it is not finalizing most of the payment proposals described above until 2021.

The Details

Currently, there are 3 to 5 levels of E/M codes depending on the practice setting (3 to 4 in facility settings and 5 for outpatient or office settings). These codes are billed based on the relative complexity of the E/M service provided, as determined in accordance with either the 1995 or 1997 guidelines issued by CMS.[2] The higher the level of E/M service (and associated relative time and resources required to deliver those services), the higher the reimbursement. According to CMS, E/M codes represent approximately 40 percent of allowed charges for PFS services, and outpatient/office visit E/M codes represent about 20 percent of total PFS allowed charges. Despite the frequency with which E/M services are performed and billed, there are a number of complexities surrounding how they are billed and the documentation required for each level of E/M code.

In an effort to alleviate this burden, CMS proposed to collapse the reimbursement for E/M level 2 through level 5 codes into a single reimbursement amount. In addition, CMS proposed to allow two new add-on codes to represent prolonged services and services with a relatively high degree of complexity. Noting the extensive time and resources that will be needed to adjust to the new coding regime, CMS has delayed the effective date of these rules until 2021. There’s time to prepare for the new E/M coding regime, and it may be altered some between now and 2021, but below is a brief overview of the finalized changes for 2021.

Collapsing Reimbursement for Levels 2-4. Importantly, CMS decided not to change the E/M codes themselves but instead chose to pay the same base reimbursement for E/M code levels 2 through 4.[3] In theory, this will reduce the level of documentation required because physicians will only need to meet the documentation requirements for a level 2 E/M code. However, it will also result in a reduction in reimbursement for many physicians who ordinarily bill higher level E/M codes, unless they also bill for one of the new add-on codes discussed below. Despite the changes in reimbursement levels, physicians do not necessarily have to change how they perform and document E/M services. In fact, CMS expects that physicians will continue to document and bill as they normally would. Noting that other government and private payors (including Medicaid, Blue Cross & Blue Shield, etc.) may continue to use the existing coding structure—or would at least need time to adjust to new coding regimes — CMS decided to retain the existing coding structure, changing the reimbursement only.

Add-On Codes. To account for the reduction in reimbursement associated with the new combined reimbursement rate for E/M levels 2 through 4 and to better align reimbursement with the resources utilized in providing E/M services, CMS decided to add two new add-on codes (again, effective 2021) that can be billed with E/M levels 2 through 4. The first is an add-on code for E/M visits for primary care and certain types of specialized medical care. The second is an add-on code to account for additional resources utilized when physicians have extended visits with patients. Despite the addition of these new codes, CMS indicated that there should not be any additional documentation requirements for E/M services.

Reducing Redundant Data Recording (effective 2019). In response to stakeholder feedback, CMS decided to remove the requirement that physicians document the medical necessity of conducting a visit in the patient’s home instead of in the physician’s office.[4] CMS also decided to streamline documentation requirements by allowing physicians to review information already contained in the medical record (review of systems and past, family and/or social history) and update it as needed, rather than re-recording all of the information.

Proposals Not Adopted. CMS decided not to adopt some of its proposals, including proposals to: (1) reduce reimbursement when E/M services are provided on the same day as a procedure; (2) establish separate podiatric E/M codes; and (3) standardize the amounts of practice expense RVUs for E/M codes.

Conclusion

Overall, there are some changes going into effect in just over a month, and others will likely be reshaped and refined over the next two years before they are implemented in 2021. For now, all physicians need to know is that they can continue to document and bill E/M codes as they always have, but in theory with less redundancy in documentation requirements.

Article contributed by Christopher L. Richard with Gilpin Givhan, PC. Gilpin Givhan, PC, is an official partner with the Medical Association.

 

[1] CMS-1693-F, available at https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-24170.pdf.

[2] 1995 Documentation Guidelines for Evaluation and Management Services, available at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf; 1997 Guidelines for Evaluation and Management Services, available at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf.

[3] CMS decided to combine levels 2 through 4 instead of 2 through 5, as originally proposed.

[4] CMS reasoned that this decision is best left to the physician and patient, without applying additional payment rules.

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CMS Releases Physician Payment Rule

CMS Releases Physician Payment Rule

This week CMS released the final physician payment rule for CY 2019. In addition to the changes to the physician fee schedule (slightly higher than the CY 2018 rate), the rule expands payment for telehealth and aligns physician interoperability requirements with hospital requirements and allows more flexibility in the physician quality reporting program. The rule finalizes a consolidated payment rate for evaluation and management (E/M) office and outpatient visit levels 2 through 4, while maintaining the payment rate for level 5 E/M visits. It also reduces payment for new Part B drugs and requires hospital outreach laboratories to begin collecting and reporting private payer payment rates and volumes. Finally, the rule will continue to allow non-excepted off-campus provider-based departments of hospitals to bill for non-excepted services on the institutional claim and will maintain payment for non-excepted services at 40 percent of the outpatient prospective payment system amount for CY 2019.

The Medical Association partnered with the American Medical Association to secure the changes.

Removing Restrictions on E/M Coding

CMS finalized several changes to E/M documentation guideline which were strongly supported by the AMA and other members of the Federation:

  • The requirement to document medical necessity of furnishing visits in the home rather than office will be eliminated.
  • Physicians will no longer be required to re-record elements of history and physical exam when there is evidence that the information has been reviewed and updated. In addition,
  • Physicians must only document that they reviewed and verified information regarding chief complaint and history that is already recorded by ancillary staff or the patient.
  • These changes will take effect 1/1/2019.

The Original Proposal Condensing Office Visit Payment Amounts and Documentation Requirements

In the 2019 proposed rule, CMS proposed to implement a single payment rate for level 2 through level 5 office visits and to reduce documentation requirements for this collapsed payment to that of a level 2 CPT visit code. The Agency proposed to continue to use existing CPT structure for office visit codes 99201-99215, though proposed to change CMS guidelines and only enforce certain aspects of the CPT structure by allowing physicians to choose the method of documentation, among the following options:

  • 1995 or 1997 Evaluation and Management Guidelines for history, physical exam and medical decision making (current framework for documentation)
  • Medical decision making only
  • Physician time spent face-to-face with patients
  • CMS had also proposed an add-on code to each office visit performed for primary care purposes and an add-on code for specialities with inherently complex E/M visits
  • CMS relayed that commenters overwhelmingly opposed the Agency’s proposed payment collapse. CMS will not finalize the proposal for CY 2019.

Other Coding/Payment Proposals Related to E/M

The following policies were also opposed and will not be implemented by CMS:

  • Payment reductions by 50 percent for office visits that occur on the same date as procedures (or a physician in the same group practice). The AMA brought attention to the fact that duplicative resources have already been removed from the underlying procedure through the current valuation process.
  • In addition, CMS proposed to no longer allow for podiatry to report CPT codes 99201-99215 and instead would use two proposed G-codes for podiatry office visits. As well as a new prolonged service code that would have been implemented to add-on to any office visit lasting more than 30 minutes beyond the office visit (ie, hour long visits in total).
  • Condensed practice expense payment for the E/M office visits, by creating a new indirect practice expense category solely for office visits, overriding the current methodology for these services by treating Office E/M as a separate Medicare Designated Specialty. This change would also have resulted in the exclusion of the indirect practice costs for office visits when deriving every other specialty’s indirect practice expense amount for all other services that they perform, which would have resulted in large changes in payment for many specialties (ie a greater than 10 percent payment reduction for chemotherapy services).

Download the CMS Factsheet.

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Big Changes Proposed for Evaluation and Management Services

Big Changes Proposed for Evaluation and Management Services

It’s been more than 20 years since the 1997 revisions to Evaluation and Management guidelines, which focus mainly on physical examination. The 2019 proposed changes provide practitioners a choice in the basis of documenting E/M visits; alleviating the burdens and focusing attention on alternatives that better reflect the current practice of medicine. The implementation of electronic medical records has allowed providers to document more information, yet repetitive templates, cloning and other workflows have pushed the envelope on compliance in documenting the traditional elements of the visit.

The proposed changes to Evaluation and Management were released in the Federal Register on July 27. The Center of Medicare and Medicaid Services is taking comments until Sept. 10, before releasing the Final 2019 Medicare Fee Schedule.

The CPT guidelines are not changing! The American Medical Association is the author of the CPT books, and there is no change in the 1995 or 1997 guidelines for E/M documentation. Medical necessity remains the overarching criteria to select a level of service. There are three proposals to reduce documentation burdens related to CMS:

Proposal One

Simplify History and Exam Documentation, allowing the physicians to focus on changes in health and allow ancillary staff to document chief complaint and history without the physician re-entering it.

Proposal Two

Remove History and Exam from E/M level decision. Currently, history and exam are two of three required elements along with medical decision-making. Medical decision-making would be the sole determinant of E/M level. Providers could use face-to-face time as a determining factor when selecting an E/M service level.

Proposal Three

Pay a single rate for Level E/M visits for the reduced burden in documentation and coding guidelines. Proposals one and two will be a package deal in proposal three. The tables below reflect the proposed payment rates.

Table A – New Patient E/M: Non-facility

Code        2018 Payment Rate     CY 2018 New Payment Rate

99201 $45 $44
99202 $76 $135
99203 $110 $135
99204 $167 $135
99205 $211 $135

 

Table B – Established Patient E/M: Non-facility

Code           2018 Payment Rate             CY 2018 New Payment Rate

99211 $22 $24
99212 $45 $93
99213 $74 $93
99214 $109 $93
99215 $148 $93

 

There are two add-on codes proposed, including one for primary care to cover inherent complexity. The primary care add-on code is GPC1X. It can only be utilized by primary care. By adding the G code to Medicare claims, internal medicine and family practice can actually earn up to five percent more revenue and reduce documentation efforts.

The add-on code available to a list of ten specialties is GPC0X. The specialties were chosen due to the inherent complexity related to E/M. The specialties eligible for this add-on code are: endocrinology, rheumatology, hematology/oncology, urology, neurology, obstetrics/gynecology, allergy/immunology, otolaryngology, cardiology or interventional pain. The big loser in this proposal is pulmonary medicine, with a reduction of 6.2 percent in revenue projected by Part B News. The big winner is urology, with a projected increase in revenue of 22 percent with the add-on code.

As a certified coder, I believe the reduction in documentation is a positive change. Most physicians were not educated on CPT coding as part of their clinical training. Physicians want to be compliant, but the guidelines are too complex to analyze during each encounter. The ancillary staff should be trained to effectively gather pertinent information to support the physician. This would allow physicians to focus on the clinical needs of the patient. CMS expects medical necessity to prevail and each encounter to stand alone in relation to the full medical record.

A proposal for 2019, we aren’t hearing about is an E/M multiple procedure payment adjustment related to duplicative resource costs when an E/M is visited and a procedure with global periods are furnished on the same day. CMS would reduce the E/M payment by 50 percent.

Administrators should review the proposed options for documentation to understand the effect on their practice. If your practice has the potential to see a negative adjustment without the option to utilize an add-on code, you should analyze the E/M dispersion pattern to understand the financial impact to your practice. For the most part, the proposed changes are positive in an effort to reduce the burden of redundant documentation. We should continue to hear much more information regarding this game-changing proposal particularly after the comment period ends on Sept. 10. The final 2019 fee schedule will be released around the first week of November. Stay tuned!

If you would like to send a comment to CMS on these changes (and we suggest you do), go to https://www.federalregister.gov/documents/2018/07/27/2018-14985/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other-revisions.

Article contributed by Tammie Lunceford, Healthcare and Dental Consultant, Warren Averett Healthcare Consulting Group. Warren Averett is an official partner with the Medical Association.

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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.

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Four Dangerous Words Physicians Regularly Say

Four Dangerous Words Physicians Regularly Say

One trend evident in all medical practices is the shift in payment responsibility from insurance payers to the insured patients. As employers modify coverage to contain their premium costs, health care providers are treating patients who have $2,500, $5,000 and even $10,000 deductibles. Physicians who have practiced for many years have instructed their collections staff with the phrase “take what insurance pays.” This brief instruction was understandable when the patient portion of the treatment was only a co-pay of $25. The additional charge to the patient’s insurance made it acceptable to extend professional courtesy to many patients. In the era of paper charts, physicians even developed a shorthand note of “TWIP” for this common habit. In the modern era of high deductibles, this habit, if not broken, will cause serious damage to the cash flow of a practice in three ways.

Decline in Cash Flow

The most immediate impact is a decline in cash flow, and since these patient payment dollars can be seen as the last dollars of revenue, the impact on physician income will be dramatic. A practice which formerly collected $1,000,000 but loses 10 percent from failure to collect patient payments will suffer a 20-percent or more decline in physician income. If practice overhead costs 55 percent of collections, there would have been $450,000 left for salaries, fringe benefits and bonuses to the doctors. If collections decline by $100,000, for continued write off of patient payments, the doctor income drops to $350,000 — a 22-percent reduction. This is an example of how daily habits can produce bad cumulative outcomes.

Staff Discouragement

In addition to this drop in profits, the extension of professional kindness can diminish the collection enthusiasm among collections staff. Physicians are quick to instruct staff to extend special dispensation to patients who are friends or socially connected to the doctor. Collections staff members tell us that the doctor refused to let them collect from people who attend the same church as the physician, share a membership in a country club or social organization with the physician or have children who share activities with the physician’s family. When this group, which most likely has the greatest capability to pay for medical care, is excused from responsibility, the collections team is no longer as enthusiastic about collecting from the patients who have no social connection to the doctor. This additional loss of revenue is never known but can be significant.

Training Patients

Finally, affording patients the discretion to pay or not fosters an environment in which the patients are more inclined to take the medical practice for granted. In working with our medical practice clients at Warren Averett, we typically see that the patients who do not pay for their portion of care are also the ones inclined to not show up for appointments, not follow clinical directions and to treat medical staff rudely. These are the patients we recommend be terminated, when possible, in their treatment. To indiscriminately extend professional courtesy regarding patient financial responsibility is cultivating a problem which could have been staunched by simply collecting what the insurance contract stipulated to begin with.

The four words “take what insurance pays” seem benign at first but can be lethal if used unchecked.

Article contributed by Sae Evans, Maddox Casey and Jim Stroud, Members, Warren Averett Healthcare Consulting Group. Warren Averett is an official Gold Partner with the Medical Association.

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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.

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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.

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CMS Updates Open Payments Data

CMS Updates Open Payments Data

On January 17, CMS updated the Open Payments dataset to reflect changes to the data that took place since the last publication on June 30, 2017. CMS updates the Open Payments data at least once annually to include updates from disputes and other data corrections made since the initial publication of the data.

The refreshed Open Payments Data Set includes:

  • Record Updates: Changes to non-disputed records that were made on or before Nov. 15, 2017, are published.
  • Disputed Records: Dispute resolutions completed on or before Dec. 31, 2017, are displayed with the updated information. Records with active disputes that remained unresolved as of Dec. 31, 2017, are displayed as disputed.
  • Record Deletions: Records deleted before Dec. 31, 2017, were removed from the Open Payments database. Records deleted after Dec. 31, 2017, remained in the database but will be removed during the next data publication in June 2018.

For More Information:

Improved Open Payments Data Website

The Open Payments Data website is enhanced to increase user accessibility, improve user experience, and provide a more robust search tool. Enhancements include:

  • Overall site redesign: The home page is reformatted with a new look and layout, featuring an updated search bar that allows users to search by physician name, teaching hospital, and reporting entity. The new layout is designed to better organize existing site content and highlight new content.
  • Fully mobile responsive site: Allows users to view the site in full on smartphones and tablets.
  • Redesigned Facts About Open Payments webpage: Includes upgraded table format displays.

Map Search Feature: Allows users to view search results via a new map feature. Users may also search by address and limit search results based on distance/radius of the specified location.

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Now Available: CMS Data Submission System for Clinicians in the Quality Payment Program

Now Available: CMS Data Submission System for Clinicians in the Quality Payment Program

CMS Launches New Data Submission System for Clinicians in the Quality Payment Program

On Tuesday, Jan. 2, the Centers for Medicare & Medicaid Services launched a new data submission system for clinicians participating in the Quality Payment Program. Clinicians can now submit all of their 2017 Merit-based Incentive Payment System data through one platform on the qpp.cms.gov website. Data can be submitted and updated anytime from Jan. 2, 2018, to March 31, 2018, with the exception of CMS Web Interface users who will have a different timeframe to report quality data from Jan. 22, 2018, to March 16, 2018. Clinicians are encouraged to log-in early to familiarize themselves with the system.

How to Login to the Quality Payment Program Data Submission System

To login and submit data, clinicians will use their Enterprise Identity Management (EIDM) credentials.

  • The EIDM account provides CMS customers with a single user identification they can use to access many CMS systems.
  • The system will connect each user with their practice Taxpayer Identification Number (TIN). Once connected, clinicians will be able to report data for the practice as a group, or for individual clinicians within the practice.
  • To learn about how to create an EIDM account, see this user guide.

Real-Time Scoring

As data is entered, clinicians will see real-time initial scoring within the MIPS performance categories. Data is automatically saved and clinician records are updated in real time. This means a clinician can begin a submission, leave without completing it, and then finish it at a later time without losing the information.

Payment Adjustment Calculations

Payment adjustments will be calculated based on the last submission or submission update that occurs before the submission period closes on March 31, 2018.

Determining Eligibility

There are two eligibility look-up tools available to confirm a clinician’s status in the Quality Payment Program. Clinicians who may be included in MIPS should check their National Provider Identifier in the MIPS Participation Status Tool, which will be updated with the most recent eligibility data, to confirm whether they are required to submit data under MIPS for 2017. For clinicians who know they are in a MIPS, APM or Advanced APM, CMS is working to improve the Qualifying APM Participant (QP) Look-up Tool to include eligibility information for Advanced APM and MIPS APM participants. We anticipate sharing this updated tool in January 2018.

For More Information

To learn more about the Quality Payment Program data submission system, please review this fact sheet or view any of the following training videos:

  1. Merit-based Incentive Payment System (MIPS) Data Submission
  2. Advancing Care Information (ACI) Data Submission for Alternative Payment Models (APMs)
  3. Data Submission via a Qualified Clinical Data Registry and Qualified Registry

Visit qpp.cms.gov to explore measures and activities and to review guidance on MIPS, APMs, what to report, and more.  

Go to the Quality Payment Program Resource Library on CMS.gov to review Quality Payment Program resources.

Questions?

Contact the Quality Payment Program at QPP@cms.hhs.gov or 1-866-288-8292 (TTY: 1-877-715-6222).

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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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