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Thursday, February 16, 2017

Executive orders and family medicine

Amid the furor surrounding other executive orders recently signed by President Donald Trump, family physicians may find one on which they can agree.

On Jan. 30, the administration issued an executive order titled, “Reducing Regulation and Controlling Regulatory Costs.” The order establishes a framework designed to reduce the cost of compliance with federal regulations. First, it provides that federal agencies, when proposing a new regulation, must “identify at least two existing regulations to be repealed.” Second, it requires that the incremental cost of any new regulation be “no greater than zero.”

The stated intention of the executive order is to decrease the cost of running a business (such as a family medicine practice), to the extent that regulations from federal agencies contribute to such costs.  The order says that all new regulations must be cost-neutral and that the net impact (new regulation minus the two repealed regulations) cannot increase "incremental costs" on the regulated community. Finally, exceptions will be considered on a case-by-case basis. 

The implementation of the order is left to the Office of Management and Budget (OMB). On Feb. 2, OMB issued to all government agencies a memo containing interim guidance and frequently asked questions on how to implement this order.  This memo clarifies that:

•    The order applies to "significant" regulations. "Significant" is not defined in the guidance, but under a 1993 Executive Order still in effect, a "significant" rule is defined as any that imposes an annual economic cost of $100 million or more.  
•    Government agencies intending to issue a “significant regulatory action” on or before Sep. 30, must first “identify two existing regulatory actions the agency plans to eliminate or propose for elimination” before the new regulation is issued.
•    Agencies must “fully offset total incremental cost” of the new regulation as of Sep. 30.
•    The costs of regulations are “measured as the opportunity cost to society,” defined as "the net benefit [a] resource would have provided in the absence of the requirement."
•    Waivers exist for regulations that address health, safety or financial emergencies. 

Future rules governing Medicare physician payment (such as those implementing the Medicare Access and CHIP Reauthorization Act of 2015, or MACRA) could be shaped by this order. Stay tuned!

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

Wednesday, February 8, 2017

Meaningful use deadlines extended to March 13

It is the season for Medicare program deadline extensions. If you are in the process of reporting your 2016 data for the Medicare Electronic Health Record (EHR) Incentive Program, also known as meaningful use, the deadline has just been extended from Feb. 28 to 11:59 pm (PT) on March 13. The Centers for Medicare & Medicaid Services (CMS) said this extension applies to those eligible professionals looking to avoid a negative payment adjustment on Medicare reimbursements in 2018.  Those participating in the Medicaid EHR Incentive Program should refer to the attestation deadlines in their particular state.  

However, there is still one critical Feb. 28 deadline remaining. If CMS has notified you that your practice failed to successfully demonstrate meaningful use for the 2015 performance year, meaning you are scheduled to receive a negative payment adjustment on all Medicare reimbursements in the associated 2017 payment year, you still must complete and submit a application to request reconsideration by the end of the month. Likewise, if you applied for a hardship exception tied to challenges in the 2015 performance year and your application was denied, you still need to complete a request for reconsideration by Feb. 28 or face negative payment adjustments this year.

The application for reconsideration and instructions related to the application are available on the CMS website for EHR Incentive programs, payment adjustments, and hardships.  For questions about the Reconsideration Application, email pareconsideration@provider-resources.com.

For questions about the Registration and Attestation System, contact the EHR Information Center at 1-888-734-6433 (option 1), which is open Monday through Friday from 6:30 am to 5:30 pm ET.

– Theresa Wilkes, Medical Informatics Strategist for AAFP

Friday, February 3, 2017

Deadline extended for certain PQRS reporting

If you are reporting to the Physician Quality Reporting System (PQRS) using the Electronic Health Record (EHR) method, you now have a little more time to submit your data. The Centers for Medicare & Medicaid Services (CMS) recently announced that it was extending the Feb. 28 deadline for PQRS submission through the EHR or qualified clinical data registry (QCDR) mechanisms.

Eligible professionals (EPs) and groups have until March 31 to submit their 2016 quality reporting document architecture (QRDA) I or III files for the EHR Direct, EHR Data Submission Vendor (DSV), and QCDR reporting mechanisms. Qualified registries and QCDRs that use XML files also have until March 31 to submit. Vendors may have their own individual deadlines that may be earlier. EPs should work directly with their vendors to ensure their data is submitted before the deadline.

EPs who fail to satisfactorily report to PQRS for 2016 will receive the maximum negative payment adjustment in 2018. EPs failing to report will also face the maximum negative payment adjustment for their group size under the Value-Based Payment Modifier Program (VBPM). Payment adjustments for the PQRS and VBPM are separate from those for the Medicare Electronic Health Record Incentive Program (a.k.a “meaningful use”). EPs have until March 13 to submit their meaningful use data. EPs can submit CQMs using the PQRS EHR reporting method or QCDR QRDA III files to fulfill the CQM requirements for both meaningful use and PQRS. EPs can contact the QualityNet Help Desk for questions about PQRS and the EHR Information Center Help Desk (1-888-734-6433, option 1) for questions relating to meaningful use.

The final year for which EPs are required to submit data for PQRS, VBPM, and meaningful use is 2016. The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 consolidates these programs into the Quality Payment Program (QPP). The first performance period for the QPP began on Jan. 1. Physicians can learn more about the QPP on the AAFP website or in the latest issue of FPM.

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

Wednesday, January 25, 2017

MIPS help offered for practices in rural and underserved areas

The Centers for Medicare & Medicaid Services (CMS) is inviting small practices that work in rural and medically underserved areas to join a webinar on Wednesday, Feb. 1, at 1:00 p.m. (Eastern Time) to learn more about participation in the Merit-based Incentive Payment System (MIPS) track of the Quality Payment Program.

During the webinar, CMS will provide information about eligibility, how to participate in MIPS in 2017, methods for submitting data to CMS, performance categories, how practices are scored, and other resources for these types of practices.

Participants will also have the opportunity to ask questions during a Q&A session.

Registration is available online: https://engage.vevent.com/rt/cms/index.jsp?seid=682

Space for this webinar is limited, so you are encouraged to register as soon as possible to secure your spot. After you register, you will receive an email message with a webinar link.

For more information on MIPS and the Quality Payment Plan in general, read this article in the latest issue of FPM.

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

Tuesday, January 10, 2017

Physicians, groups to get breather on PQRS penalties

It seems the most recent round of updates to ICD-10 coding has caused enough concerns at the Centers for Medicare & Medicaid Services (CMS) that the agency is temporarily eliminating payment penalties based on those changes.

The CMS this week announced that the changes are expected to affect its ability to process data for certain quality measures within the Physician Quality Reporting System (PQRS). As a result, individuals and groups that fail to satisfactorily report 2016 PQRS data solely because of the 2016 coding changes will not face 2017 or 2018 PQRS negative payment adjustments. Those who fail to satisfactorily report for reasons other than coding, however, are still at risk.

The changes affected a variety of measures, but the majority related to diabetes, pregnancy, cardiovascular, oncology, mental health, and eye disease diagnosis. This includes the diabetes, cataracts, oncology, cardiovascular prevention, and diabetic retinopathy measures groups.

Even if you believe the changes to ICD-10 affected your ability to meet the reporting requirements satisfactorily, CMS still expects you to report to PQRS. Once the 2016 reporting period ends, CMS plans to conduct an analysis to review and determine which submissions were negatively affected by the ICD-10 changes. Individuals and groups that feel they have received a negative payment adjustment as a result of the ICD-10 changes will also be able to file an informal review.

CMS advises that eligible professionals (EPs) should use the codes in the measure specification sheets for their respective reporting mechanism. Qualified registry, electronic health record, and qualified clinical data registry vendors should continue to calculate the measures according to their particular measure specification sheet.

EPs and vendors can contact the QualityNet Help Desk for assistance. CMS has also published frequently asked questions.

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

Friday, January 6, 2017

Medicare’s Quality Payment Program is coming; two opportunities to get ready

The new year has begun, which means the Medicare’s Quality Payment Program (QPP) becomes even more important as what you do (or don’t do) in 2017 may affect your Medicare payments in 2019. The Centers for Medicare & Medicaid Services (CMS) is offering two opportunities this month to get a leg up now on the new QPP.

First, CMS is conducting a Clinical Practice Improvement Activities Study and will accept applications for the study through Jan. 31. CMS says it is leading this study to examine clinical workflows and data collection methods using different submission systems and to understand the challenges facing physicians and other clinicians when collecting and reporting quality data. The agency says it will use this information to recommend ways to eliminate burdens, improve collection and reporting of quality data, and enhance clinical care.

Study participants must meet the following requirements between January and December of this year:

•    Complete at least three survey questionnaires.
•    Participate in at least three focus groups.
•    Submit at least three clinician quality performance measures to CMS.

If you or your physicians group is eligible for the Merit-based Incentive Payment System (MIPS) and successfully participates in the study, CMS will award you full credit for the Improvement Activities performance category of MIPS. Participants will also get direct feedback from other study participants and CMS during the study on how to reduce problems with data collection and submission.

For more information and to apply to participate in the study, please visit the CMS website. You should submit your completed applications to CMSCPIAStudy@ketchum.com by Jan. 31.

CMS will also host a call titled “Medicare Quality Programs: Transitioning from PQRS to MIPS” on Tuesday, Jan. 24, from 2:00 p.m. to 3:30 p.m. (EST). During this call, you can find out how to complete the final reporting period for the legacy Medicare quality reporting programs and transition to MIPS.

To register, please visit MLN Connects Event Registration. CMS is evaluating this call for continuing medical education credit. Please refer to the call detail page for more information.

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

Tuesday, December 20, 2016

2015 quality data now available on Physician Compare website

The Centers for Medicare & Medicaid Services (CMS) this week published quality data for 2015 on the Physician Compare website. The data included selected 2015 Physician Quality Reporting System (PQRS) measures, non-PQRS measures, and Consumer Assessment of Healthcare Providers and Systems (CAHPS) measures for both individual physicians and group practices or accountable care organizations (ACOs).

Depending on how the data was reported, the newest batch of information includes the following data from 2015:
     •    90 individual clinician-level PQRS measures collected through claims and registry, and 16 non-PQRS measures collected through Qualified Clinical Data Registries (QCDRs) for approximately 175,000 individual clinicians;
     •    91 group practice-level PQRS measures collected via the web interface and registry and eight CAHPS measures for approximately 2,500 group practices
     •    19 Shared Savings Program and Pioneer ACO measures for approximately 400 ACOs.

The release does not include any measures reported by electronic health record for 2015 because that information continues to be plagued by data integrity issues.

Since starting the Physician Compare website in 2010, CMS has continued to enhance the site to provide data that is both useful to consumers and assists them to make informed health care decisions. CMS also believes transparency motivates better physician performance.

Each measure is scored using a star-rating system with each star representing 20 percent of the total score (e.g., five stars is 100 percent, four stars is 80 percent, etc.)

This information is important to physicians because it reflects on their reputation and may influence potential patients to either seek out or avoid a practice. The CMS plans to eventually add information collected under the Medicare Access and CHIPS Reauthorization Act (MACRA) such as data for each of the four Merit-based Incentive Payment System categories (quality, cost, improvement activities, advancing care information) and final scores. Advanced Alternative Payment Model data will also be available, similar to ACO data now.  Item-level benchmarking will be incorporated into the star rating system.

CMS will host webinars on Feb. 21 and 23 about recent updates to Physician Compare. Additional information regarding these events, including registration information, will be available soon. If you have any questions about Physician Compare or the 2015 performance scores release, contact the CMS Physician Compare contractor at PhysicianCompare@Westat.com.

– Sandy Pogones, MPA, CPHQ, Senior Strategist for Health Care Quality for the American Academy of Family Physicians

Friday, December 16, 2016

Changes to renewing DEA registration for physicians

Update: After this blog item was originally posted, the DEA announced that it had reversed its decisions to eliminate a second registration renewal notice to prescribing physicians and eliminate the grace period for renewals after Jan. 1. Instead, the DEA said it would retain its current policies and procedures for renewing DEA registration although registrants will now receive the second renewal notification at the email address associated with their registration instead of through the mail.

There are many moving parts to practicing as a family physician and one of those is being able to prescribe needed medications for your patients. That depends on having a valid, current registration with the U.S. Drug Enforcement Administration (DEA).

The DEA recently announced significant changes to its registration renewal process. Effective Jan. 1, the DEA is eliminating the informal grace period that the agency had previously allowed for registrants to renew their registrations. The DEA will send only one renewal notice to each registrant’s “mail to” address approximately 65 days before the expiration date; DEA will provide no other reminders to renew the DEA registration.

The DEA also advises that physicians who fail to file a renewal application by midnight Eastern Standard Time of the expiration date will have their DEA number “retired” and have to apply for a new one. The agency also says after the expiration date physicians won’t be able to renew a DEA registration online and the DEA won’t accept paper renewal applications.

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

Friday, December 2, 2016

University of Colorado clinic wins 2016 FPM Award for Practice Improvement

The University of Colorado School of Medicine Department of Family Medicine has won this year’s Family Practice Management (FPM) 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 Newport Beach, Calif.

FPM Editorial Advisory Board member John Bachman, MD, presented the award to the department’s medical director, Corey Lyon, DO.

The program was recognized for its success in implementing a team-based model to address access issues, poor outcomes, and burnout. Implementation included increasing provider support with additional medical assistants and support staff, and expanding their roles.

“Culture will eat strategy for breakfast, lunch, dinner, and a midnight snack,” Lyon said. “We had to move beyond the culture of ‘I can’t do that. That’s not how we do it.’”

After one year, monthly visits increased 25.6 percent. Staff costs per visit were unchanged, but monthly charges increased 20 percent. Additionally, provider self-reported burnout was reduced by half.

CMS extends deadline to review value modifier and PQRS results

The Centers for Medicare & Medicaid Services (CMS) has extended until Dec. 7 the deadline for family physicians and others to request an informal review of their value modifier and Physician Quality Reporting System (PQRS) results, which will otherwise impact Medicare physician payments in 2017.

CMS released the 2015 annual Quality and Resource Use Reports (QRURs) on Sept. 26. The 2015 annual QRURs show how physician groups and solo practitioners performed in 2015 on the quality and cost measures used to calculate the 2017 Value Modifier as well as their 2017 Value Modifier payment adjustment.

You can access and review your 2015 annual QRUR now to determine whether you are subject to the 2017 Value Modifier payment adjustment. You will need an Enterprise Identity Management (EIDM) account with the appropriate role to obtain your 2015 annual QRUR. The CMS web site contains instructions for signing up for the appropriate role in EIDM and instructions for accessing the QRUR. Also available on this webpage is a streamlined instructional guide for accessing the QRUR titled “Quick Access Guide for the 2015 Annual QRURs and Tables.”

Physician groups or solo practitioners may request an informal review of perceived errors in their 2017 Value Modifier calculation during the informal review period, which now expires on Dec. 7 at 11:59 p.m. (EST). Additional information about the 2015 Annual QRURs and how to request an informal review is available on CMS’s 2015 QRUR and 2017 Value Modifier webpage.

In 2017, CMS will apply a downward payment adjustment to those who did not satisfactorily report under the Physician Quality Reporting System (PQRS) in 2015.

If you have any questions regarding the status of your 2015 PQRS reporting or are concerned about potentially receiving the PQRS downward payment adjustment in 2017, you can also submit an informal review request for that and ask CMS to investigate your payment adjustment determination. However, again, you must do so by Dec. 7. CMS will be in contact with every individual eligible professional or PQRS group practice that submits a request for an informal review of their 2015 PQRS data and notify them via email of a final decision within 90 days of the original request for an informal review. All CMS decisions will be final, and there will be no further review.

Follow these steps to submit an informal review request:
1.    Go to the Quality Reporting Communication Support Page (CSP).
2.    In the upper left-hand corner of the page, under “Related Links,” select “Communication Support Page.”
3.    Select “Informal Review Request.”
4.    Select “PQRS Informal Review.”
5.    A new page will open.
6.    Enter Billing/Primary Taxpayer Identification Number (TIN), Individual Rendering National Provider Identifier (NPI), OR Practice Site ID # and select “submit.”

Complete the mandatory fields in the online form, including the appropriate justification for the request to be deemed valid. Failure to complete the form in full will result in the inability to have the informal review request analyzed. CMS or the QualityNet Help Desk may contact you for additional information if necessary. Please see the PQRS informal review fact sheet for more information.

Additionally, 2015 PQRS feedback reports can be accessed on the CMS Enterprise Portal using an EIDM account. For details on how to obtain your report, please see the “Quick Reference Guide for Accessing 2015 PQRS Feedback Reports.” For information on understanding your report, please see the “2015 PQRS Feedback Report User Guide.” Both guides are on the PQRS Analysis and Payment webpage on the CMS web site.

For More Help:
•    For additional assistance regarding EIDM or to ask questions about the informal review process, contact the QualityNet Help Desk at 1-866-288-8912 (TTY 1-877-715- 6222) from 7:00 a.m. to 7:00 p.m. Central Time, Monday through Friday, or via email at qnetsupport@hcqis.org. To avoid security violations, do not include personal identifying information, such as Social Security Number or TIN, in e-mail inquiries to the QualityNet Help Desk.
•    For additional assistance regarding the QRUR or the Value Modifier, contact the Physician Value Help Desk at pvhelpdesk@cms.hhs.gov or 888-734-6433 (select option 3).

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

Monday, November 28, 2016

New code required in 2017 for telehealth services

Beginning Jan. 1, the Centers for Medicare & Medicaid Services (CMS) is creating a new place of service (POS) code for physicians who provide telehealth services from a distant site. POS code 02 is described as “The location where health services and health related services are provided or received, through telecommunication technology.”

Under HIPAA, non-medical code sets, such as POS, are paid based on what code set was in effect on the date of the transaction, not the date of service. So even if the date of service was in 2016, if you initiate the claim on or after Jan. 1, you should use the new POS code.

Note that you must still use modifiers GT (via interactive audio and video telecommunications systems) and GQ (via an asynchronous telecommunications system) when billing Medicare for telehealth services. If you bill POS code 02 but without the GT or GQ modifier, your Medicare administrative contractor (MAC) will deny the service. Your MAC will also deny the service if you bill for telehealth services with modifiers GT or GQ but without POS code 02.

CMS has provided additional information on this change through the Medicare Learning Network.

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

Tuesday, November 15, 2016

New influenza vaccine code delayed until Jan. 1

If you are dispensing influenza vaccines under a new CPT code this fall, the Centers for Medicare & Medicaid Services (CMS) is suggesting that you do not send those claims in for payment right away.

This summer, CMS was scheduled to accept a new CPT code for influenza vaccine. The code, 90674, describes “Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, preservative and antibiotic free, 0.5 mL dosage, for intramuscular use.” The CPT Editorial Panel accepted the code at its February meeting, and it will appear in the 2017 CPT book. CMS previously disclosed a payment allowance of $22.936 for code 90674, beginning for services provided on or after Aug. 1.

But CMS recently announced that Medicare claims processing systems will not be able to accept code 90674 until Jan. 1.

In the meantime, CMS advises that you hold claims containing that code until then. Also, if you bill institutional claims, CMS says that code 90674 will be implemented on Feb. 20.

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

Thursday, November 10, 2016

New pay increases in the 2017 Medicare physician fee schedule

The Centers for Medicare & Medicaid Services (CMS) has released its final rule on the 2017 Medicare physician fee schedule. Some of the several increases for care management services in 2017 will interest family physicians. For example, CMS next year will begin paying for:

• Non-face-to-face prolonged evaluation and management services

• Comprehensive assessment and care planning for patients with cognitive impairment

• Primary care practices to use interprofessional care management resources to treat behavioral health conditions

• Chronic care management (CCM) for patients with more complex conditions

In addition, CMS is trying to encourage more practices to offer and bill for CCM services by reducing the administrative burden associated with those codes.

CMS also will revalue existing codes describing face-to-face prolonged services. For 2017, CMS has set the Medicare conversion factor at $35.8887, which is slightly higher than the 2016 conversion factor of $35.8043. CMS expects that the provisions of the final rule will generate an estimated 1 percent increase in Medicare allowed charges for family physicians.

CMS has provided additional information in a fact sheet on the final rule.

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

Wednesday, November 2, 2016

How to avoid E/M errors and denials

The Centers for Medicare & Medicaid Services (CMS) says approximately 15 percent of evaluation and management (E/M) services are improperly paid and accounted for 9.3 percent of the overall Medicare fee-for-service improper payment rate in 2014. To help you avoid improper payment of your E/M claims and prevent payment denials, CMS has released a new fact sheet of compliance tips for E/M services.

According to the fact sheet, E/M claims are typically denied for two reasons: incorrect coding, such as the code not matching the documentation, and insufficient documentation, which can include a lack of a physician signature or no record of the extent and amount of time spent in counseling and/or coordination of care when it is used to qualify for a particular level of E/M service.

To prevent your E/M claims being denied, CMS recommends a number of strategies. First, in addition to the individual requirements for billing a selected E/M code, you should also consider whether the service is “reasonable and necessary.” For example, while it is possible to provide and document a level 5 office visit for a patient with a common cold and no comorbidities, it is unlikely that anyone would consider that level of service reasonable and necessary under those circumstances.

Another strategy is to remember the following key variables when selecting codes for E/M services:
•    Patient type (new or established)
•    Setting/place of service
•    The level of service provided based on the extent of the history, the extent of the examination, and the complexity of the medical decision making (i.e., the number and type of the key components performed)

Finally, the fact sheet emphasizes the need to obtain the necessary physician/non-physician provider signatures. You can find links to additional CMS resources and references at the end of the fact sheet.

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

Monday, October 31, 2016

Comprehensive Primary Care Plus program reopening to practices

Practices that missed the application deadline for the Comprehensive Primary Care Plus (CPC+) program will have another opportunity to apply next year.

The Centers for Medicare & Medicaid Services (CMS) recently announced it was reopening CPC+ applications for both payers and practices. Delays in the initial payer application process this summer shrunk the two-month practice application window by two weeks. Many practices felt this was not sufficient time to evaluate the program and determine if the added payment associated with CPC+ would support the amount of work necessary to comply with the program. 

In addition, at that time only one region in the original Comprehensive Primary Care initiative had achieved shared savings, which led some to believe it was not a successful program. On Oct. 17, CMS announced that four of the seven participating regions experienced net savings for 2015, the program’s second performance year.

The CPC+ program is one of the payment models recognized as an Advanced Alternative Payment Model (APM) in the final rule of the Quality Payment Program (QPP), part of the Medicare Access and CHIP Reauthorization Act. Participation in an Advanced APM offers physicians the opportunity to receive a 5 percent bonus payment.

CMS has not yet provided additional details on next year’s reopening of the CPC+ application process. In the meantime, you can learn more about the CPC+ application requirements by reviewing the original Request for Applications.

Kristen A. Stine, MSOD, Practice Transformation Strategist at the American Academy of Family Physicians

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