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
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.
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
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
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
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.
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.”
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
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
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.
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
CMS beefing up screening of Medicare-enrolled providers
To help combat Medicare fraud – and weed out those most responsible for it – the Centers for Medicare & Medicaid Services (CMS) is making changes in how providers enroll and remain in the Medicare system.
CMS plans to publish a new rule in the Federal Register tomorrow that creates added requirements for those enrolling to become Medicare providers and gives the agency tools to find and terminate enrolled providers who have shown a history of fraud. This has added significance as many physicians are coming up on the end of their five-year Medicare revalidation cycle and will be submitting information to maintain their billing privileges.
Among the changes:
• Providers would have to disclose connections to other providers or suppliers who have had their Medicare, Medicaid, or CHIP enrollment denied or revoked; have uncollected debt to those programs; or have had their payment suspended under a federal health care program or because of an Office of Inspector General exclusion.
• CMS could deny or revoke Medicare enrollment if it discovered a provider's Medicare enrollment has been revoked under a different name or identity. Also, it could deny or revoke Medicare enrollment if a provider’s license has been revoked in one state and he or she is applying or enrolled in a different state or if the provider has been terminated from a state Medicaid or other federal health care program under a current or different name or identity.
• The agency could revoke the physician's enrollment for what CMS considers an "abusive" or dangerous pattern or practice of ordering, referring, certifying, or prescribing Medicare Part A or B services, items, or medications.
• The length of time someone can be barred from re-enrolling in Medicare would increase, including a maximum 20-year ban for a second revocation.
• CMS would require that physicians and others who order, certify, refer, or prescribe any Part A or B service, item, or medication must be either enrolled in Medicare or have a valid opt-out.
Meanwhile, CMS is boosting its existing methods for screening Medicare providers by increasing site visits to Medicare-enrolled providers, replacing the current Provider Enrollment Chain and Ownership System (PECOS) with software that can also look for invalid addresses, and deactivating on a monthly basis enrolled providers who have not billed Medicare in the last 13 months.
The upshot is that while physicians have always needed to be careful when submitting documentation to accept Medicare patients, you may now need to increase those efforts, even if you don't have any Medicare skeletons lurking in your past.
New insurer database tool could cut back on phone calls to physicians
The Council for Affordable Quality Healthcare (CAQH) has created a centralized way for physicians to update their information in insurance plan directories and reduce the amount of time they spend talking to insurance companies.
The nonprofit alliance of insurers and health care providers has created DirectAssure, a database that coordinates with CAQH’s current ProView tool used by more than 800 health plans for such things as credentialing.
CAQH said it will contact physicians designated by participating health plans at least once a quarter to ask them to review and update their information. Physicians can then log on to the system for free and update their location, contact information, specialty, and group/institution affiliation, as well as whether they’re accepting new patients.
CAQH said the health plans can check the DirectAssure system to make sure their directories are correct, instead of a physician receiving several calls from the plans themselves.
Besides making things easier for physicians, the new system is aimed at meeting new federal and state requirements that health plans do a better job of keeping their provider databases current and accurate and more useful to patients.
Medicare: Physicians are mixing up E/M codes for skilled nursing facilities
It seems there’s room for improvement in how many physicians code for evaluation and management (E/M) services provided to patients in skilled nursing facilities (SNFs).
The Centers for Medicare & Medicaid Services (CMS) recently said its auditors found that physicians and non-physician practitioners (NPPs) are reporting incorrect codes for E/M services provided to SNF Medicare patients.
Specifically, physicians and NPPs are using CPT codes 99221-99223 (initial hospital care), 99231-99233 (subsequent hospital care), and 99238-99239 (hospital discharge day management) to bill for E/M services supplied to SNF patients. However, those codes are for E/M services supplied to hospital patients.
As described in the Medicare Claims Processing Manual Section 30.6.13, E/M services provided to patients residing in an SNF must be reported using the appropriate CPT level of service code within the range identified for initial nursing facility care (99304-99306) and subsequent nursing facility care (99307-99310). The annual nursing facility assessment is billed using CPT code 99318, and SNF discharge services are billed using CPT codes 99315-99316. Using an inpatient hospital E/M CPT code represents inappropriate billing when you render E/M services in an SNF.
Part of the confusion may stem from the fact that the patients in question are in hospital “swing beds,” which can represent either inpatient hospital or nursing facility care, depending on how the hospital is billing Medicare for its services. Section 30.6.9.D of the Medicare Claims Processing Manual advises that if the hospital is billing Medicare for the patient’s inpatient care as inpatient hospital care, the hospital care CPT codes apply for purposes of reporting physician services to the patient. If the hospital is billing Medicare for the patient’s inpatient care as nursing facility care, then the nursing facility CPT codes apply for physician services. So, if in doubt about the status of a Medicare patient in a “swing bed,” check with the hospital regarding how it is billing Medicare for the patient’s inpatient care and adjust your coding accordingly.
– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians
CMS gives physicians more time to attest to 2015 meaningful use
The Centers for Medicare & Medicaid Services (CMS) has extended the attestation deadline for the meaningful use program. Eligible Professionals (EPs) now have until 11:59 PM ET on Friday, March 11, to attest to the 2015 reporting year. The previous deadline was Feb. 29. Failure to attest will result in a 3 percent cut to your 2017 Medicare Part B payments.
EPs must attest to a continuous 90-day period between Jan. 1, 2015, and Dec. 31, 2015. Those scheduled to attest to Stage 2 will report on 10 objectives, while EPs scheduled to attest to Stage 1 will have alternate measures and exclusions available to them for 2015. Attestation is completed through the online Registration and Attestation System. You must have a National Plan and Provider Enumeration System (NPPES) web user account to log on. If someone is attesting on your behalf (such as a practice administrator) that individual must have an Identity and Access Management web user account and must be granted the appropriate authorizations to complete the attestation.
This announcement is the latest of many regarding meaningful use in recent months. In October, CMS released a final rule that, among other things, condensed Stages 1 and 2 into Modified Stage 2 and announced the Stage 3 objectives. Last month, CMS was granted the authority to streamline its exception process. Providers have until March 15 to submit a hardship application to avoid the 2017 payment adjustment. Also in January, acting administrator Andy Slavitt announced that the meaningful use program will be ending as a standalone program as the Medicare Access and CHIP Reauthorization Act (MACRA) is implemented in 2019.
– Erin Solis, Regulatory Compliance Strategist for the American Academy of Family Physicians
Want to use this article elsewhere? Get Permissions
Current Issue of FPM
Search This Blog