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Thursday, April 21, 2016

Medicare keeping vigilant on observation services

If you or your practice provides observation care at a local hospital to Medicare patients, the Centers for Medicare & Medicaid Services (CMS) is issuing a gentle reminder to pay attention to your documentation for those services – if you don’t want to face a refund request.

In the latest issue of CMS’s Medicare Quarterly Provider Compliance Newsletter, the agency indicates it is keeping a close eye on physician billing for hospital observation services. In the article, “Comprehensive Error Rate Testing (CERT): Observation Services,” CMS notes that evaluation and management (E/M) services, such as observation services, remain a leading cause of improper Medicare payments. CMS also notes that most improper payments were due to insufficient documentation, such as:

•    No order for observation services
•    No progress notes
•    No physician’s signature on a progress note

As an example, CMS describes the case of a physician who billed Medicare for CPT 99217 (“Observation care discharge”) for a date of service in April 2013. However, the submitted documentation was missing signed and dated physician’s orders for observation services and was also missing a signed and dated progress note to support a face-to-face encounter on the date of service. The physician was unable to produce any documentation to support that he or another member of his group had seen the patient on the date of discharge from observation. Subsequently, the Medicare administrative contractor recovered the payment.

The article also reminds physicians that even when documentation is present, it must support the level of E/M observation service claimed. Failure to document the level of service claimed also constitutes a potential overpayment as far as Medicare is concerned.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Wednesday, April 13, 2016

CMS provides details on Comprehensive Primary Care Plus

Like an auto company touting the latest model or a certain soda manufacturer unveiling its “new” version of an old “classic,” the Centers for Medicare & Medicaid Services (CMS) has revealed its latest effort to transform and improve how primary care is delivered and paid for in the United States. CMS will implement the Comprehensive Primary Care Plus (CPC+) model in up to 20 regions of the country, accommodating up to 5,000 practices and more than 20,000 physicians and other clinicians. It would also seek to encompass up to 25 million patients.

Building on the Comprehensive Primary Care initiative launched in late 2012, which is already being dubbed “CPC Classic,” the five-year CPC+ model will offer primary care practices two tracks for participation. Both tracks will require practices to:

•    Support patients with serious or chronic diseases to achieve their health goals
•    Give patients 24-hour access to care and health information
•    Deliver preventive care
•    Engage patients and their families in their own care
•    Work together with hospitals and other clinicians, including specialists, to provide better coordinated care

Practices in Track 2 will also be expected to provide more comprehensive services for patients with complex medical and behavioral health needs, including, as appropriate, a systematic assessment of their psychosocial needs and an inventory of resources and supports to meet those needs.

Physicians participating in CPC+ will receive monthly care management fees for eligible beneficiaries in their practice. Physicians in Track 1 will be paid depending on where each patient falls across four risk tiers, with an average of $15 per beneficiary per month. In Track 2, physicians will be paid according to five risk tiers, with an average of $28 per beneficiary per month, including $100 per month for the most complex patients. Practices can use these fees for increased staffing and training necessary to meet the model’s patient care requirements.

In addition to the care management fees, Track 1 physicians will continue to receive their normal Medicare fee-for-service payments. Physicians in Track 2 will receive a new hybrid of fee-for-service payments and a “Comprehensive Primary Care Payment,” which will include a percentage of the expected Medicare reimbursement for Evaluation & Management (E/M) claims upfront. Reimbursement for the E/M claims themselves will be reduced.

In addition to these payments, CMS will award practices incentives based on performance.

Like CPC Classic, Medicare will partner under the CPC+ model with commercial and state health insurance plans. CMS will accept proposals from payers wanting to partner in CPC+ between April 15 through June 1, selecting regions of the country that reflect sufficient interest from multiple payers. Practices in the selected regions can apply to participate from July 15 through Sept. 1.

CMS is offering additional information on CPC+ through a press release, a fact sheet, and frequently asked questions.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Friday, April 8, 2016

Open Payments review and dispute period ends May 15

Physicians and teaching hospitals have until May 15 to review financial information reported about them under the “Open Payments” system and dispute information they believe is incorrect before the information is released to the public on June 30.

The Centers for Medicare & Medicaid Services (CMS) annually asks pharmaceutical and medical device manufacturers and group purchasing organizations to report all payments or other transfers of value they made to physicians and teaching hospitals during the previous year. The June 30 release includes information for 2015, along with updates to the databases for 2013 and 2014.

The review process is voluntary, but to participate and file disputes, you will need to register in both the CMS Enterprise Identity Management System (EIDM) and the Open Payments system itself.

If you registered last year, you don’t have to register again. Go to the CMS Enterprise Portal, log in using your user ID and password, and navigate to the Open Payments system home page. If you haven’t accessed your account in the last 60 days, you will need to answer some challenge questions and then reset your password. If you haven’t visited in more than 180 days, you’ll have to contact openpayments@cms.hhs.gov to reinstate your account.

Thursday, April 7, 2016

CMS releases 2015 mid-year Quality and Resource Use Reports

The Centers for Medicare & Medicaid Services (CMS) has released the mid-year Quality and Resource Use Reports (QRURs) for 2015. These reports are released annually and serve as a tool for physicians to review their performance on a subset of measures that will be used to calculate the 2017 Value-Based Payment Modifier (VBPM).

The mid-year QRURs are for informational purposes only and cover the performance period between July 1, 2014, and June 30, 2015. This performance period differs from the actual performance period that will be used to calculate the 2017 VBPM. The reports contain data on six cost measures and three claims-based quality outcome measures.

While the performance information included on the mid-year QRUR may differ from the 2015 QRUR, which comes out in the fall, the report still offers physicians a good opportunity to review their performance and implement quality improvement activities for the upcoming year. A physician’s performance in 2016 will be used to calculate his or her 2018 VBPM.  

CMS has created resources on how to use your 2015 mid-year QRUR as well as how to obtain the report.

-- Erin Solis is the regulatory compliance strategist for the American Academy of Family Physicians

Wednesday, April 6, 2016

Groups can now register for the 2018 PQRS

Physician practices wanting to use the Group Practice Reporting Option (GPRO) to participate in the 2018 Physician Quality Reporting System (PQRS) have until June 30 to register. If not, all providers within the group must report to PQRS as individuals or face a Medicare pay penalty in 2018.

The Centers for Medicare & Medicaid Services (CMS) defines a “group” as a single Tax Identification Number (TIN) with two or more individual providers with National Provider Identifiers (NPIs) who have reassigned billing rights to the TIN. Groups can register using an Enterprise Identity Management (EIDM) account. CMS encourages users to create or modify existing EIDM accounts now to avoid delays. If you are unsure if someone in your group is already enrolled with the EIDM system, contact the QualityNet Help Desk. You will need the group’s TIN and name.

During registration, you will select your reporting method. Your choices are:
•    Qualified PQRS Registry
•    Electronic Health Record (EHR)
•    Qualified Clinical Data Registry (QCDR)
•    Web Interface (for groups with more than 25 providers)

Physicians wanting to report using the EHR or QCDR methods will need to be sure that their vendors meet the requirements for group reporting. Additionally, groups with between two and 99 eligible professionals (EPs) will need to decide if they want to supplement their reporting with the Consumer Assessment of Health Care Providers and Systems (CAHPS) for the PQRS survey. CAHPS is required for groups with 100 or more EPs.

All groups and solo physicians will be subject to the 2018 Value Modifier. Participation in the PQRS program will help you avoid the automatic downward payment adjustment for failure to satisfactorily report.

--Erin Solis is the regulatory compliance strategist for the American Academy of Family Physicians

Tuesday, April 5, 2016

Compensation for family physicians rises in new survey

Family physicians saw their average overall compensation increase last year, and they felt slightly less anxious about their pay and their profession, according to a new report.

The Medscape Physician Compensation Report 2016, released April 1, reported that family physicians made an average of $207,000 in total compensation in 2015, up 6 percent from the previous year. Most specialties saw gains in annual compensation, with the highest-paid physicians being orthopedists with an average of $443,000. The lowest-paid specialty was pediatrics with an average of $204,000.

In addition to receiving higher pay, 52 percent of all physicians (and 52 percent of family physicians) said they believed their compensation was fair. By comparison, half of all physicians and 48 percent of family physicians felt they were fairly compensated in 2014. Dermatologists (66 percent) felt the most comfort with their compensation, while urologists (42 percent) were the least satisfied. Among family physicians, 73 percent said they would still choose medicine as a career if they had to do it all over again, which is up from 69 percent five years ago. The percentage of family physicians who would stick with the specialty, however, has fallen from 44 percent in 2011 to 29 percent now.

The trend of physicians choosing to work for hospitals and other large health care groups appeared to remain steady with 35 percent of men and 23 percent of women sticking with private practice, virtually the same percentages as a year ago.

Male and female compensation continued to have a disparity, but it is shrinking. Male family physicians made an average of $220,000 versus $183,000 for female family physicians, a difference of 20 percent. The difference was 28 percent in 2011. Also, survey results showed that female physicians faced a similarly sized pay gap regardless of whether they were employed or self-employed.

Despite the continued focus on “direct primary,” “concierge,” or “direct pay” care models, those types of practices remain very much in the minority. Only 10 percent of family physicians reported being in a concierge or cash-only practice, the same amounts as in 2014. The researchers said it appeared private practice physicians looking to get away from the regulatory and financial headaches of traditional practice are more likely to go into employed positions rather than go the direct-pay route.

The survey also said 39 percent of family physicians were in an accountable care organization (ACO) and 7 percent planned to join one in the coming year. By comparison, 35 percent belonged to one in 2014 and 8 percent planned to join one.

Thursday, March 31, 2016

CMS answers questions about chronic care management

On March 17, the Centers for Medicare & Medicaid Services (CMS) answered some common questions about chronic care management (CCM) services. Among the highlights:

•    CMS states that if a skilled nursing facility, nursing facility, or assisted living facility meets all the CCM billing requirements and it is not receiving payment for care management services, you may bill CPT 99490 for CCM services furnished to beneficiaries there. The place of service on the claim should be the billing location (i.e., where the billing practitioner would furnish a face-to-face office visit with the patient).

•    CMS specifies that levels 2 through 5 evaluation and management (E/M) visits qualify as “comprehensive” visits for CCM initiation. CMS is not requiring the practice to initiate CCM during a level 4 or 5 E/M visit. However, CPT codes that do not involve a face-to-face visit by the billing practitioner or are not separately payable by Medicare do not meet the requirement for the visit that must occur before CCM services are furnished.

•    CMS indicates that it will give the billing practice some latitude in situations where the billing practice has the ability to send clinical summaries or the electronic care plan by way of an acceptable electronic technology other than fax, but the receiving practice/provider (which is not billing for CCM services) can only receive the required information by way of  fax.

For additional information, a fact sheet on CCM is available on the CMS website. The agency also notes that the scope of service elements and other requirements for billing CCM to the Medicare physician fee schedule (MPFS) are laid out in the calendar year 2014 and 2015 MPFS final rules (CMS-1600-FC, CMS-1612-FC and CMS-1612-F2), which are also available on the CMS web site.

– Kent Moore, senior strategist for physician payment for the American Academy of Family Physicians

Wednesday, March 30, 2016

MGMA-AMA encourage collaboration to solve health care challenges

Almost 350 physicians, practice administrators, and other health care leaders met in Colorado Springs, Colo., March 20-22 for the inaugural Collaborate in Practice Conference, sponsored by the Medical Group Management Association (MGMA) and the American Medical Association.

The event was billed as a way to help practices better handle the many challenges facing medicine through better teamwork, leadership, and collaboration among physicians, other clinicians, managers, and other partners.

Halee Fischer-Wright, MD, president and CEO of MGMA, said that health care can’t just confront change but needs to control it or, better yet, lead the way.

Breakout sessions focused on such topics as making team meetings more effective, refining and reinforcing your practice’s culture, finding ways to give patients more access so they don’t gravitate to other providers, and increasing physician engagement to fend off burnout.

Some takeaways from the sessions:

• 71 percent of malpractice suits are tied to miscommunication and poor physician-patient relationships. Practices should focus on fighting dysfunction within teams, defusing toxic relationships that can affect patient care, and create the kind of supportive environment where patients are more likely to share their own personal or social issues that could influence treatment. – Monica Broome, MD

• All team meetings should have a specific purpose and goal. Meetings are a vital sign for your organization, and useless or unsuccessful meetings may reflect a structural problem within the practice. – Steven Bromer, MD

• Practice administrators or physician leaders will have more success changing clinician behavior by appealing to their mastery, autonomy, and sense of purpose. Framing a change simply as a response to regulatory requirements is not helpful. – Stephen Beeson, MD

• To increase patient satisfaction, have nurses call patients the day after a visit, which can either make a satisfied patient even happier or give a dissatisfied patient a chance to complain before it becomes more work for the practice; take advantage of the perceived connection between cleanliness and good care by keeping your office clean; make sure the receptionist always makes eye contact with the patient upon entering; and try to give patients the appointment times they want so you don’t run the risk of the patient showing up late and throwing off your entire schedule. – William Faber, MD

• Leaders should not feel the need to be perfect in all facets of leadership. Instead, they should lead with their strengths, such as execution or motivation, and rely on their team to make up for their weaknesses. – Wayne Guerra, MD

• When done correctly, incorporating health care information technology into your practice can improve patient engagement, physician workflow, and, ultimately, physician happiness. Introduce technology innovations slowly, aim for short-term gains, but ultimately lay the groundwork for big wins down the road. – Lyle Berkowitz, MD

Monday, March 28, 2016

CMS answers billing questions on advance care planning

Medicare began paying for advance care planning services on Jan. 1. As with most new reimbursement programs released by the Centers for Medicare & Medicaid Services (CMS), physicians have had questions. Last week, CMS attempted to answer some of them.

Advance care planning services are described by two Current Procedural Terminology (CPT) codes:

•    99497, Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate.
•    +99498, Each additional 30 minutes (List separately in addition to code for primary procedure).

Among the highlights in the CMS’s answers:

•    CMS will follow CPT provisions regarding minimum time required to report the service; that means a unit of time is attained when the mid-point is passed.
•    CMS has not established any frequency limits for these services.
•    There are no place of service or physician specialty limitations on the codes.
•    Medicare administrative contractors will determine any documentation requirements.
•    Completion of an advance directive is not required to bill the service.
•    Advance care planning can be reported in addition to other evaluation and management services, except certain critical care services.
•    No specific diagnosis code is required with advance care planning codes.
•    These services are subject to the usual Part B deductible and coinsurance unless furnished as an optional element of the Medicare annual wellness visit.

For additional information, CMS encourages you to read pages 70955-70959 of the final rule on the 2016 Medicare physician fee schedule and Medicare Learning Network Matters article MM9271.

– Kent Moore, senior strategist for physician payment for the American Academy of Family Physicians

Thursday, March 17, 2016

Fee-for-service still dominant force in reimbursement

Federal officials want to move quickly to transition Medicare reimbursement away from models based solely on volume of services.

A new study demonstrates how far they need to go.

In results published in Health Affairs, the study found that only 5 percent of patient office visits in 2013 were paid based on capitation arrangements and the remaining 95 percent were all some form of fee-for-service.

The researchers, using data mined from the annual Medical Expenditure Panel Survey, noted that capitation, which sought to shift some or all of the financial risk for providing patient care to physicians, has seen a steady decline in acceptance since its inception in the 1990s and especially during the 2000s.

New models, such as those detailed in the Medicare Access and CHIP Reauthorization Act of 2015, are designed to reward physicians based on value and quality of patient care. Supporters believe value-based care is less expensive and could reduce the number of unnecessary tests, procedures, and other services that can go unchecked under fee-for-service. However, many physicians worry that attempts to measure value and quality will be cumbersome and ineffective, and could penalize them unfairly.

The researchers suggested that physicians may be more willing to embrace value-based care than they were to embrace capitation, but they acknowledged physicians' reluctance. “Providers’ willingness to participate in new payment mechanisms will likely be closely tied to the extent that they are required to assume risk,” the study said.

Largely because of this, fee-for-service remains a key mechanism for paying physicians even within organizations set up to emphasize value, such as accountable care organizations.

Thursday, March 10, 2016

Study: Practices spend $15.4 billion a year to measure quality

Physicians often complain about the time they have to spend filling out documentation and other forms to report quality measure information.

A new study published in Health Affairs attempted to quantify the problem and found that practices in primary care and three other common specialties spend an average of 785 hours per physician annually on entering quality information into computers, reviewing quality reports generated by external entities, tracking quality measure specifications, implementing processes for collecting data, and transmitting that information to third parties for quality measurement.

Multiplied by the average compensation for each type of physician and staff member, the study estimated U.S. practices spend more than $15.4 billion a year to report these quality measures.

Of the four specialties – which included primary care (family medicine and internal medicine), cardiology, orthopedics, and multispecialty practices that included primary care – the primary care physicians spent the most time and money on quality measures.

The study said those practices spent an average of 19.1 hours per physician per week on quality measurement with the physicians alone spending 3.9 hours. Annually, those practices spent an average of $50,468 per physician.

By comparison, cardiology practices said they spent 10.4 hours a week (1.7 hours for physician only) and $34,924 a year while orthopedic practices said they spent 11.3 hours a week (1.1 hours for physician) and $31,471 a year.

Multispecialty practices said they spent 17.6 hours a week. Researchers did not include financial information for multispecialty practices because the practices include specialties outside the study’s scope.

The study, paid for by The Physicians Foundation, was based on surveys of more than 300 practices contacted through the Medical Group Management Association database.

Researchers said 81 percent of respondents reported spending more time and money meeting quality measurement requirements now than three years ago and only 27 percent said they believed the measures actually represented quality care.

In addition, the report found that federal programs, state and regional agencies, and health insurers often use hundreds of quality measures that share very little in common with one another, compounding the work practices must perform to comply with all their requirements.

“There is much to gain from quality measurement,” the study authors write, "but the current system is far from being efficient and contributes to negative physician attitudes toward quality measures.”

Wednesday, March 9, 2016

Majority of physician groups see no change under Value Modifier program

The Centers for Medicare & Medicaid Services (CMS) has released the results of the 2016 Value Modifier (VM). The VM lowers or raises a physician’s Medicare payments based on his or her performance on quality and cost measures. The 2016 results, which apply to physician groups of 10 or more eligible professionals (EPs), are based on data reported in 2014.

Of the 13,813 physician groups with 10 or more EPs, only 128 groups exceeded the program’s quality and cost benchmarks. These groups will receive an increase of either 15.92 percent or 31.84 percent in their payments under the Medicare Physician Fee Schedule. Physicians in 59 groups will see their payments reduced by 1 percent or 2 percent based on their performance on quality and cost measures. There were 5,418 groups who failed to meet the reporting requirements and will face an automatic 2 percent cut. The remaining 8,208 groups will not face any adjustment because of their performance or because there was insufficient data to calculate their VM.

Medicare Administrative Contractors will process claims based on the updated adjustment amounts beginning March 14. Claims with a date of service prior to this will automatically be reprocessed. Groups should see the adjustments on their claims within the next six weeks.

Beginning in 2017, the VM will apply to solo physicians as well as those in groups of two or more physicians. To avoid an automatic payment decrease, physicians should report to the Physician Quality Reporting System (PQRS). Physicians can pull their annual Quality Resource and Use Report (QRUR) to review their performance on quality and cost measures and see how they will fare under the VM.

--Erin Solis, Regulatory Compliance Strategist for the American Academy of Family Physicians

Monday, March 7, 2016

Medicare contractor clarifies "incident-to" rules for allergy therapy

Medicare’s “incident-to” rules become less mysterious the more you learn about them. But that doesn’t mean physicians and practice administrators aren’t still sometimes baffled by how they work.

Earlier this year at a forum, Wisconsin Physician Services (WPS), a Medicare administrative contractor, answered a question about providing allergy therapy that surprised many. In essence, the question was: If a nurse in the practice administers allergy injections to a patient, can the practice bill the service under the physician's Medicare provider number, even though the physician is not treating the allergy?

In its response, WPS referenced Medicare Learning Network Matters article Special Edition (SE) 0441, which addresses incident-to rules. WPS noted that one of the requirements of incident-to billing is that the billing physician is the one treating the patient for that condition or situation. So, if the physician in question is treating the patient for the allergy (not just providing the injections), then this situation could meet the incident-to requirements.

If the physician is not treating the patient for the allergy, then, according to WPS, this situation does not meet the incident-to requirements, and the physician cannot bill for the administration of the injection. WPS advises notifying the patient of non-coverage in this scenario.

Even if this particular situation wasn’t on your radar, it should show that incident-to rules are definitely being scrutinized by Medicare administrative contractors.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Thursday, March 3, 2016

You’ve made the switch to ICD-10 coding. Now what?

It’s been more than five months since ICD-10 became the required standard for coding and billing patient encounters in the United States, and the Centers for Medicare & Medicaid Services (CMS) wants to make sure your office is using ICD-10 not just correctly but productively. CMS has released the Next Steps Toolkit, a free resource that offers specific suggestions and recommendations in these areas:

Assessing your progress. Practices should compare current performance to a pre-ICD-10 baseline or establish a baseline for making future comparisons. Tracking key performance indicators such as rates of rejection and denial is the first step to improvement.

Addressing your findings. Systematically collecting and answering questions from staff and analyzing your clinical documentation and code selection as needed can help head off future problems and fix current ones.

Maintaining your progress. Physicians should make sure their systems capture annual ICD-10 updates, which take place in October.

For more information, visit CMS’s ICD-10 website and other resources, including this list of contacts, by state, for Medicare and Medicaid questions. 

Tuesday, March 1, 2016

Deadline for meaningful use hardship exception extended

The Centers for Medicare & Medicaid Services (CMS) has extended the deadline for physicians and other providers to submit hardship exceptions for the meaningful use (MU) program. Providers now have until July 1 to apply for an MU exception. An exception would allow them to avoid the 2017 payment adjustment for failure to meet the reporting requirements in 2015. The previous deadline was March 15. CMS encourages providers to submit their applications electronically as soon as possible to avoid delays.

Applying for and receiving an exception does not prevent a provider from potentially receiving an incentive payment if they successfully attest for 2015 later. The exception simply protects the provider from the payment adjustment should they be unsuccessful in their attestation. Those who are unable to attest at all and fall into any of the exception categories may also submit an application.

The Meaningful Use attestation deadline is March 11. Additionally, providers can satisfy the Clinical Quality Measure (CQM) requirement of MU by reporting on Physician Quality Reporting System (PQRS) measures using the Electronic Health Record (EHR) method. The deadline for this is also March 11.

--Erin Solis, Regulatory Compliance Strategist for the American Academy of Family Physicians

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