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Friday, February 5, 2016

Diabetes foot exams among changes in 2016 PQRS

The 2016 version of the Physician Quality Reporting System (PQRS) included a number of changes, but the revised diabetes foot exam is especially important to note because it requires more work than the measure it replaced.

The previous measure, “Diabetes: Foot Exam,” asked for a visual inspection of the foot along with a sensory exam using a monofilament and a pulse exam. The new measure, “Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurological Evaluation,” specifies that the sensory exam include a monofilament plus one of the following: vibration using 128-Hz tuning fork, pinprick sensation, ankle reflexed, or vibration perception threshold. This exam only needs to happen once a year, but it is important to document correctly.

In addition, the new measure, with some exceptions, applies to all patients with diabetes over the age of 18. The previous measure covered patients ages 18-75.

Remember, physicians who do not meet PQRS requirements in 2016 face a 2-percent cut in Medicare payments in 2018.

– Amy Mullins, MD, Medical Director of Quality Improvement, American Academy of Family Physicians

Tuesday, February 2, 2016

CMS aligning Medicaid and Medicare home health requirements

Last week, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that adds new requirements for Medicaid home health services. Among the new requirements is that physicians document a face-to-face encounter with Medicaid patients before ordering the home health services or certain related medical equipment. This rule aligns Medicaid with similar regulatory requirements for Medicare.

Specifically, the final rule requires that when first ordering home health services (nursing services and home health aide services) the physician must document that a face-to-face encounter related to the primary reason the patient needs home health services took place no more than 90 days before or 30 days after the start of services. If initially ordering medical supplies, equipment, or appliances, the physician or an authorized non-physician provider (NPP) must document that the face-to-face encounter occurred no more than six months prior to the start of services. In both cases, the physician or certain authorized NPPs must be the one performing the face-to-face encounter.

The final rule is effective on July 1. However, CMS recognizes that state governments and physicians may need time to deal with the operational and financial effects of the changes. Accordingly, CMS is delaying compliance with this rule for up to one year (July 1, 2017) if a state’s legislature has met in that year or two years (July 1, 2018) if not. A CMS fact sheet offers additional information.

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

Friday, January 29, 2016

Survey: EHR adoption continues to increase, information sharing limited

The percentage of office-based physicians using federally certified electronic health record (EHR) systems continued to climb in 2014 although the number sharing patient information with third parties was limited, according to new federal data.

The Centers for Disease Control and Prevention, referencing the National Electronic Health Records Survey, says 74.1 percent of physicians in 2014 reported having a certified EHR, up from 67.5 percent in 2013. Primary care physicians, including family physicians, were more likely to have a certified EHR (78.6 percent) compared with non-primary care specialists (70.3 percent).

Researchers theorized that incentives provided through the Centers for Medicare & Medicaid Services’ meaningful use program helped encourage physicians to adopt certified EHRs.

One of the goals of persuading physicians to adopt EHRs is so they can share medical history, lab results, medication, and other patient information with other physicians and hospitals as the patient moves between health care providers.

The survey showed that 32.5 percent of physicians with certified EHRs were electronically sharing patient information with third-party ambulatory physicians or nonaffiliated hospitals. By comparison, only 16.8 percent of physicians without a certified EHR were sharing information with those third-parties.

The numbers were even smaller for electronically sharing patient information with other types of health care providers. The survey found that 15.2 percent of those with certified EHRs said they shared information with home health providers, 13.6 percent shared with long-term care providers, and 14 percent shared with behavioral health providers.

Wednesday, January 27, 2016

CMS sets submission deadlines for 2015 PQRS data

Have you submitted your 2015 Physician Quality Reporting System (PQRS) data yet? If not, you still have time to do so without incurring a penalty in 2017.

The Centers for Medicare & Medicaid Services (CMS) has announced the 2015 PQRS data submission deadlines, which vary depending on how you plan to submit your data:

•    Electronic Health Record Direct or Data Submission Vendor (quality reporting data architecture I/III) – Feb. 29
•    Qualified Clinical Data Registries (quality reporting data architecture III) – Feb. 29
•    Group Practice Reporting Option Web Interface – March 11
•    Qualified Registries (such as the PQRS Wizard) – March 31
•    Qualified Clinical Data Registries XML – March 31

All submission deadlines end at 8 p.m. (EST) on the date listed. You will need an Enterprise Identity Management (EIDM) account with the “Submitter Role” for these PQRS data submission methods. Please see the EIDM System Toolkit for additional information.

Also, be aware that the Physician and Other Health Care Professionals Quality Reporting Portal may be unavailable while the system is undergoing maintenance. Maintenance is currently scheduled for the following time frames (all times are EST):

•    Feb. 26 at 8 p.m. – Feb. 29 at 6 a.m.  
•    March 11 at 8 p.m. – March 14 at 6 a.m.  
•    March 16 at 8 p.m. – March 21 at 6 a.m.  

Eligible professionals who do not satisfactorily meet the 2015 PQRS requirements will be subject to a reduction in payment on all Medicare Part B Physician Fee Schedule services rendered in 2017.

For questions, please contact the QualityNet Help Desk at 1-866-288-8912 or via email at from 8 a.m. – 8 p.m. (CST). Complete information about PQRS is available on the CMS web site.  

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

Tuesday, January 26, 2016

New rules available for requesting MU hardship exceptions

Congress has provided additional details for physicians wanting to claim a hardship exception from the Medicare Electronic Health Record (EHR) Incentive Program, also known as “meaningful use” (MU). In December, President Obama signed into law the Patient Access and Medicare Protection Act (PAMPA), which gave Congress the authority to streamline the exception process.

The updated process reduces the amount of information required to apply for an exception. For example, multiple providers can now use the same exception application. Also, the Centers for Medicare & Medicaid Services (CMS) can review applications based on “categories” rather than on a case-by-case basis. These categories include: insufficient Internet connectivity, extreme and uncontrollable circumstances, lack of control over Certified EHR Technology (CEHRT) availability, and lack of face-to-face patient interaction.

Physicians who did not successfully meet the MU requirements for the 2015 reporting year may apply for a hardship exception. If granted, the exception would protect the physician from the negative payment adjustment that would have been applied in 2017. An exception is effective for one year – physicians must reapply each year they wish to be exempted. A new eligible professional (EP) who began submitting Medicare claims in 2015 does not need to apply for an exception.

If you want to use the streamlined exception process, you need to submit your application by March 15. CMS will notify applicants of its determinations by email. All decisions are final and cannot be appealed. CMS encourages the use of the electronic application to avoid potential processing delays.

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

Thursday, January 21, 2016

Open Payments system gets an update – and a time out

The Centers for Medicare & Medicaid Services (CMS) has updated its Open Payments database, which tracks payments and "transfers of value" to physicians and teaching hospitals from pharmaceutical and medical device manufacturers or group purchasing organizations.

CMS typically updates the information at least once a year to address disputed payments and other corrections made since the data was first reported. The database now covers $9.9 billion in financial information submitted during the program's initial two years.

The Open Payments Data website now has added functionality, allowing visitors to search by name for payments tied to a doctor and view summaries of trends found in the data.

The Open Payments system itself is undergoing maintenance Jan. 21-26. Physicians won’t be able to access the system during this time, but the public website will still be available.

Visit CMS' Open Payments program website for more information and the Resources website if you still haven’t registered. Registration is required before physicians can review payments or transfers of value tied to their name and file a dispute or correction.

Thursday, January 14, 2016

Surveyed physicans say burnout is increasing

A new study indicates the ongoing focus on physician burnout is not unwarranted. The number of physicians unhappy in their practices is on the upswing.

Medscape’s Lifestyle Report 2016 found that the burnout rate for physicians in 25 specialties surveyed went up from past studies. Fifty percent or more of respondents from a dozen specialties reported a lack of personal accomplishment, cynicism about their work, and a general lack of joy coming into the office.

Among those were family physicians, 54 percent of whom said they were burned out.

On a scale of one to seven, with seven being the worst, family physicians rated their feelings of burnout at 4.37. This was the seventh-highest severity rating, tied with cardiologists. Critical care physicians reported a slightly higher rating at 4.74. Psychiatrists reported the lowest rating at 3.85.

Female physicians again reported a higher prevalence of burnout (55 percent) than their male counterparts (46 percent), although both genders have seen a steady increase since 2013 (45 percent and 37 percent, respectively).

Respondents identified increased bureaucratic tasks as the leading cause of their burnout, although working too many hours, increasing use of computers, and inadequate income also scored highly.

The survey, which polled almost 16,000 physicians, also asked about potential biases toward specific groups of patients and how likely those biases affected the treatment they provided. It found that overall 40 percent of physicians reported some level of bias, with family physicians reporting the fourth-highest level at 47 percent. The highest was among emergency medicine physicians (62 percent), while the lowest was among pathologists (10 percent), a specialty that rarely deals with patients directly.

In terms of whether bias affected patient treatment, 11 percent of family physicians said it did, the same rate as orthopedists, psychiatrists, and rheumatologists. The highest rates were 14 percent of emergency medicine physicians and 12 percent of plastic surgeons. The survey noted that of those who reported that their biases affected how they treated their patients, 29 percent said the effect was negative, 25 percent said it was positive (e.g., overcompensation and special treatment), and 24 percent said it was a mix of the two.

The survey also suggested there may be a relationship between burnout, which can cause depersonalization, and bias. Forty-three percent of physicians who reported burnout also reported bias, whereas 36 percent of physicians who did not report burnout reported bias.

Tuesday, January 5, 2016

CMS to require prior authorization for certain durable medical equipment

Starting next month, the Centers for Medicare & Medicaid Services (CMS) will begin requiring prior authorization for certain durable medical equipment, prosthetics, orthotics, and supplies.

The move, effective Feb. 29, follows several years of efforts by CMS to reduce fraud and overuse of these items, also known as DMEPOS.

Most recently, CMS implemented the DMEPOS Competitive Bidding Program and increased screening of suppliers, as authorized by the Affordable Care Act. In addition, CMS started a prior authorization demonstration program for power mobility devices, eventually expanding the trial from seven to 19 states.

The new process goes well beyond power mobility devices. It creates a “master list” of 135 DMEPOS items, a subset of which will be subject to prior authorization. CMS will publish this “required prior authorization list” 60 days before implementation.

If prior authorization is required for an item, the requester (usually the DMEPOS supplier) must provide CMS evidence that the item complies with all applicable Medicare coverage, coding, and payment rules. This must be done before the item is provided to the Medicare recipient or a claim is filed for processing. While the supplier will typically provide this information, prescribing or ordering physicians should not be surprised if the supplier asks their office for assistance.

After CMS receives the Medicare documentation, the agency or its review contractors will conduct a medical review and decide whether to provisionally affirm the request. Medicare will pay claims filed with a provisional affirmation if other requirements are met. Claims with a non-affirmation or no decision will be rejected, although the agency will allow unlimited resubmissions of prior authorization requests.

Medicare says it or its review contractors will try to process prior authorization requests within 10 business days and process resubmitted requests within 20 business days. Expedited review will be available in certain circumstances, such as instances where waiting the normal time frame for prior authorization could seriously endanger the life or health of the patient.

CMS will also communicate specific prior authorization guidance in the future.

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

Monday, December 21, 2015

Congress passes legislation to provide meaningful use relief

Physicians who face potential Medicare payment cuts in 2017 because they can't meet new requirements for the meaningful use program in 2015 may soon get a reprieve.

Congress has passed legislation that requires the Centers for Medicare & Medicaid Services (CMS) to grant a hardship exemption from those penalties to any physician who requests one by March 15. The bill now goes to President Obama for his signature.

CMS released modifications to the meaningful use program in October, including new rules for Stage 2. For 2015, physicians may attest to the program by reporting any consecutive 90 days during the year.

Previously, CMS could provide hardship exemptions on a "case by case" basis. But the legislation's supporters, as well as several medical associations, said the late release of the Stage 2 changes means many physicians do not have enough time to meet the regulations and should be granted an automatic exemption. Failing to achieve meaningful use in 2015 can lead to a reduction in Medicare payments in 2017.

UPDATE: President Obama signed the bill into law on Dec. 28.

CMS offers new date of service option for transitional care management

Previously, we described what's changing in the new Medicare Physician Fee Schedule, based on what the Centers for Medicare & Medicaid Services (CMS) published in the final rule on the 2016 fee schedule. Buried in that same rule was a change in how physicians can report the date of service for transitional care management (TCM) services.

Before publication of the final rule, CMS had written that the 30-day period for the TCM service began on the day of discharge and continued for the next 29 days – making the reported date of service the 30th day. However, in the final rule for 2016, CMS wrote:

"Regarding TCM services, we are adopting the commenters’ suggestions that the required date of service reported on the claim be the date of the face-to-face visit, and to allow (but not require) submission of the claim when the face-to-face visit is completed, consistent with current policy governing the reporting of global surgery and other bundles of services under the [physician fee schedule]."

CMS went on to state that it will revise the existing sub-regulatory guidance for TCM services accordingly. CMS provided no timetable for that revision. Most aspects of the final rule are not effective until Jan. 1, so you should probably not adjust your TCM billing practices before then. You should probably also confirm with your Medicare Administrative Contractor that it is prepared to handle TCM claims as described by CMS before submitting such claims.

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

Friday, December 18, 2015

CMS releases new quality data on Physician Compare website

The Centers for Medicare & Medicaid Services (CMS) recently released 2014 data on the quality of care provided by individual health care professionals, group practices, and accountable care organizations (ACOs). It is part of the agency’s ongoing effort to provide useful and current quality performance data to Medicare beneficiaries who are looking for a physician. These data are now available on Physician Compare.

The 2014 data that CMS released include:

•    Additional performance scores on preventive care, diabetes, cardiovascular care, and patient safety by some physician group practices and ACOs
•    New performance scores on patients’ experiences with some physician group practices and ACOs
•    The first set of individual health care professional performance scores on preventive care, cardiovascular care, and patient safety measures

This information is obviously important for physicians as it could influence new Medicare patients to either seek out or avoid your practice or encourage existing Medicare beneficiaries to change providers.

CMS will host a series of one-hour webinars to discuss these recent updates and the future of Physician Compare, including a publicly reported benchmark. CMS will conduct the webinars through WebEx at the following dates and times:

•    Tuesday, Feb. 23, at 12 p.m. ET/ 9 a.m. PT
•    Wednesday, Feb. 24, at 4 p.m. ET/ 1 p.m. PT
•    Thursday, Feb. 25, at 11 a.m. ET/ 8 a.m. PT

All sessions will present the same information, and CMS will send registration details before each session. In the meantime, if you have any questions about Physician Compare or the 2014 quality measure release, contact the CMS Physician Compare contractor at

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

Friday, December 11, 2015

Specialty-specific ICD-10 coding resources available

The Centers for Medicare & Medicaid Services (CMS) has released a new ICD-10 guide, Resources for Specialties and Selected Health Conditions and Services, aimed at helping physicians and coders properly code common health conditions through ICD-10.

The guide deals with almost two dozen conditions, services, and specialties, including a section devoted to family medicine. Other sections discuss ICD-10 coding for abdominal pain, asthma, cardiology, diabetes, obesity, lab services, and even specific conditions like strep throat and being struck by a vehicle.

The guide is part of CMS’s ICD-10 educational initiative and has direct links to its clinical concept guides, interactive case studies, medical case studies, and webcasts.

Family Practice Management has its own set of ICD-10 coding resources in the FPM Toolbox.

Monday, December 7, 2015

CMS offers help for new Meaningful Use program rules

The Centers for Medicare and Medicaid (CMS) has released new resources for physicians and other providers making sense of the recent changes to the Electronic Health Record Incentive Programs, also known as Meaningful Use (MU).

A variety of information sheets are available to eligible professionals (EPs) to help them successfully attest to MU in 2015. The resources include an overview that outlines key changes to the program, a tip sheet highlighting specific criteria for 2015, and specification sheets and tables covering the program’s measures and objectives. CMS has also included an attestation worksheet that providers can use to record their numerators and denominators as a reference during the attestation process. These resources are all available on the CMS website. Additional resources will be added to the website as they are available.

In October, CMS released its final rule for the EHR Incentive Program, effectively condensing it down to two stages – a modified Stage 2 and a new Stage 3. Stage 1 has been eliminated from the program. For reporting year 2015, CMS is allowing providers who were scheduled to attest to Stage 1 to use alternate measures and exclusions. Additionally, CMS removed measures that were considered redundant or “topped out,” leaving a total of nine objectives for Stage 2. Starting in 2017, providers will have the option to attest to the Stage 2 or Stage 3 requirements. Stage 3 will be mandatory for all providers beginning in 2018.

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

Friday, December 4, 2015

University of Florida department wins 2015 FPM Practice Improvement Award

The University of Florida Department of Community Health and Family Medicine has won this year’s Family Practice Management Award for Practice Improvement. The department was presented with the award Friday during the Society of Teachers of Family Medicine Conference on Practice Improvement being held in Dallas, Texas.

Former FPM Editorial Advisory Board member Kenny Lin MD, MPH, presented the award to the department’s program director, Peter Carek, MD.

The program was recognized for its inpatient readmission project that addressed high rates of readmission to the university hospital after discharge. A team that included family medicine physicians, emergency medicine physicians, pharmacists, nurses, social workers, and home health providers created and implemented a high-risk patient discharge plan.

During the 10 weeks before the project started, the family medicine inpatient service's readmission rate averaged 23 percent. For the 20 weeks following implementation of the project, the readmission rate decreased to 18 percent, an absolute reduction of 5 percent and a relative reduction of 22 percent.

– Lindsey Hoover, assistant managing editor, Family Practice Management.

Tuesday, December 1, 2015

Deadline approaching for changing Medicare participation/non-participation status

Physicians and other providers have until Dec. 31 to update their Medicare participation status for 2016. They have three options – participation, non-participation, and opting out – and the decision to elect participation or non-participation is binding throughout the calendar year.

Participating providers agree to accept all Medicare assignments and Medicare’s approved reimbursement amounts. Medicare pays 100 percent of the approved Medicare rate, with 80 percent of the payment coming directly from Medicare and the remaining 20 percent coming from the patient or the patient’s supplemental insurance. Participating physicians are not allowed to bill the patient directly. Medicare Administrative Contractors (MACs) process participating providers’ claims more quickly than those of non-participating providers.

Non-participating providers may accept Medicare assignments on a claim-by-claim or patient-by-patient basis. In return, they receive 95 percent of the Medicare-approved rates for participating physicians, although they can charge more than the Medicare-approved amount for unassigned claims. The maximum charge allowed for unassigned claims, or “limiting charge,” is 115 percent of the Medicare-approved amount for non-participating providers.  

Providers who opt out of Medicare enter into private contracts with Medicare beneficiaries and can bill the patients directly. Once a provider has opted out, he or she cannot submit claims to Medicare for two years.  Providers may choose to opt out at the beginning of any calendar quarter by submitting an opt-out affidavit to his or her MAC within 30 days of the beginning of the selected quarter. It is important to note that opting out is specific to the provider. A physician who opts out and changes practices will still not be able to submit claims to Medicare until the two-year opt-out period has expired.

To find out your participation status, you can search the Medicare Provider List. For questions regarding Medicare participation, contact your MAC. More information on Medicare is available on the AAFP website.

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

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