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Friday, July 14, 2017

CMS releases physician payment proposals for 2018

The Centers for Medicare & Medicaid Services (CMS) this week released its proposed rules on the 2018 Medicare physician fee schedule (PFS). The proposal would increase overall rates in 2018 by 0.31 percent, effectively increasing the PFS conversion factor by a dime to $35.99.

Among the many proposals that are highlighted in a fact sheet on the proposed rule and on which CMS is seeking comments, the proposed rule would:

•    No longer require physicians report the telehealth modifier for professional claims, which would reduce administrative burdens.
•    Adopt CPT codes in 2018 for reporting several care management services currently reported using Medicare G-codes.
•    Require physicians to begin using and reporting on their claims the Medicare Appropriate Use Criteria (AUC) for advanced diagnostic imaging. There would be an educational and operations testing year in 2019, meaning that CMS would continue to pay claims for advanced diagnostic imaging services regardless of whether they contain information on the required AUC consultation.
•    Implement in 2018 the Medicare Diabetes Prevention Program expanded model.
•    Use Level II HCPCS modifiers on claims to indicate patient relationship categories on a voluntary basis beginning Jan. 1.

Also, CMS is seeking recommendations on updating the documentation guidelines for evaluation and management (E/M) services to reduce the associated burden and better align E/M coding and documentation with the current practice of medicine. CMS is especially focused on the documentation guidelines for history and exam, which CMS believes may be more significantly outdated.

In addition to the payment and policy proposals, CMS is releasing a Request for Information (RFI) for other proposals to improve transparency, flexibility, program simplification, and innovation. These answers will guide future regulatory action related to the PFS.

Comments are due to CMS by Sept. 11.

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

Monday, July 3, 2017

CMS expands prior authorization for DME

Prior authorization is the bane of many family physicians’ existence. Despite their pleas for relief, the Centers for Medicare & Medicaid Services (CMS) has announced its intent to expand prior authorization for two pieces of durable medical equipment (DME).

The items in question are both power wheelchairs represented by the following Healthcare Common Procedure Coding System codes:
•    K0856: Power wheelchair, group 3 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds.
•    K0861: Power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds.

Last December, CMS said it would begin requiring prior authorization for these items in Illinois, Missouri, New York, and West Virginia, beginning for items furnished on or after March 20. Now, CMS said it intends to expand that prior authorization requirement nationwide, beginning for items furnished on or after July 17.

Suppliers of these products will require prior authorization as a condition of payment, so if you prescribe or order a power wheelchair for a Medicare patient, do not be surprised if the supplier requests additional documentation to facilitate the prior authorization. Also, do not be surprised if it takes your patient longer to receive the equipment while the prior authorization process plays out.

For additional information on DME prior authorization under Medicare, you can visit the Prior Authorization Initiatives page on the CMS web site. Also, CMS is hosting a Special Open Door Forum (conference call) on the subject on July 6 at 2 p.m. (Eastern Time). To access the call, dial 1-800-837-1935 and mention conference ID # 37139406. CMS will post a transcript and audio recording of this Special Open Door Forum to the Special Open Door Forum website for downloading sometime after the call.

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

Monday, June 19, 2017

How to get ready for new Medicare cards

In an attempt to prevent fraud and fight identity theft, Medicare is issuing new identification cards to beneficiaries next year that no longer carry their Social Security numbers. Considering that your practice likely uses these cards to make sure you include the right insurance information and patient identifier on claims, this change will affect you too.

The Centers for Medicare & Medicaid Services (CMS) will issue new Medicare cards with a new unique, randomly-assigned number called a Medicare Beneficiary Identifier (MBI) to replace the existing Social Security-based Health Insurance Claim Number (HICN). CMS will start mailing new cards to Medicare beneficiaries in April 2018 and replace all Medicare cards by April 2019.

Your practice systems will need to be able to accept the new MBI format by next April, CMS encourages you to work with your billing vendor to make sure that your system is updated to reflect these changes.

However, to make this change easier for you and your business operations, there is a 21-month transition period during which all health care professionals will be able to use either the MBI or the HICN for billing purposes. CMS will also soon allow health care professionals to look up a patient’s new MBI through a secure tool at the point of service.

So, here are five steps you can take today to help your office get ready:

1.    Go to CMS’s provider website and sign up for the weekly MLN Connects newsletter.

2.    Attend CMS’s quarterly calls to get more information. CMS will let you know when calls are scheduled in the MLN Connects newsletter.

3.    Verify all your Medicare patients’ addresses. If the addresses you have on file are different than the Medicare address you get on electronic eligibility transactions, ask your patients to contact Social Security and update their Medicare records.

4.    Work with CMS to help your Medicare patients adjust to their new Medicare card. This fall Medicare will issue posters and other helpful information about the new Medicare cards that you can hang in your offices.

5.    Test your system changes and work with your billing office staff to be sure your office is ready to use the new MBI format.

To learn more, visit:

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

Wednesday, May 24, 2017

Medicare to require updated notice of noncoverage form

Family physicians occasionally provide services to Medicare patients for which they expect they will be denied reimbursement because they do not meet Medicare coverage rules. In those instances, they may inform their patients of the situation with a form called an Advance Beneficiary Notice of Noncoverage (ABN). The ABN allows the patient to make an informed decision about whether to still receive the service, knowing that he or she may have to pay for it out of pocket.  

In March, the federal Office of Management and Budget renewed the ABN (Form CMS-R-131) and its instructions for another three years. The new forms are largely unchanged, except for the new expiration date of March 2020 and new language informing beneficiaries of their rights under Centers for Medicare & Medicaid Services (CMS) nondiscrimination practices and how to request the ABN in an alternative format. Physicians will need to use the updated ABN form beginning June 21, although you can begin using it immediately if you wish.

CMS has published guidelines for mandatory and voluntary use of the ABN in the Medicare Claims Processing Manual, Chapter 30, Section 50. The revised form and additional information is available on the CMS Beneficiary Notices Initiative webpage.

– 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

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

Tuesday, October 11, 2016

New limited English proficiency rule to start Oct. 17

Sometimes, “getting paid” means implementing regulations as cheaply as possible without running afoul of the law. Such is the case with a federal rule that goes into effect next week.

Beginning Oct. 17, the U.S. Department of Health and Human Services (HHS) will require most physician practices to notify patients with limited English proficiency (LEP) of their freedom from discrimination and of the availability of language assistance services. This rule applies to all health programs or activities that receive funding from or are administered by HHS and the health insurance marketplaces as well as all plans offered by issuers that participate in those marketplaces. For instance, if you receive Medicaid payments or a “meaningful use” incentive payment, this rule applies to you. However, if your practice’s only source of federal funds is through Medicare Part B, then this rule does not apply to you.

To comply with the rule, your practice must ensure “meaningful access” for those with LEP by adhering to the following requirements:

•    You must post a notice of nondiscrimination in English and may combine the content of the notice with other notices required under other federal laws.
•    You must post taglines written in the top 15 languages in the state where your practice does business indicating that language assistance is available. HHS has determined the top 15 languages for each state. Ideally, the language of the tagline should be in the language to which it refers; HHS has translated resources on its website.

You must post the notices in a sufficiently prominent and noticeable place in your office, and the rule requires that you post the language assistance taglines on all “significant publications or communications.” This means items that would result in substantial consequences if the patient did not understand (e.g., notice of a treatment plan or a termination of coverage). If the publication or communication is electronic, it must have a link to the notice of nondiscrimination and 15 taglines on the bottom. If it is paper, the publication must have the statement of nondiscrimination and taglines, unless it is something small, like a postcard. In those cases, it only needs the statement of nondiscrimination and the tagline in the top two languages. The notice of nondiscrimination and top 15 taglines should also be at the bottom of your website.

If you have not already done so, now would be a good time to develop a plan to address the needs of patients with LEP. Ideally, the plan should include all languages frequently used in the practice, even if they are not included in the top 15 languages in your state. You may also consider signing up with a language assistance call center to help with the translation of documents as well as telephonic or in-person interpretation when needed. For example, some states’ Medicaid programs regard medical interpretation as a covered service and contract with a vendor to provide it. Your local hospital may also have interpreter resources. Finally, you should consider having commonly used documents translated for frequently used languages.

Enforcement of the new rule will fall to HHS’s Office of Civil Rights, which has indicated that it will use a flexible, context-specific analysis to determine any violations on a case-by-case basis. For additional information, check out the HHS summary and fact sheets and training materials .

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

Wednesday, September 21, 2016

Codes for smoking and tobacco cessation counseling are changing

As part of its quarterly update to the Medicare physician fee schedule database, the Centers for Medicare & Medicaid Services (CMS) is changing the way you report smoking and tobacco cessation counseling to Medicare.

Effective for services on or after Oct. 1, CMS will no longer consider valid for Medicare purposes CPT codes G0436 (Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 3 minutes, up to 10 minutes) and G0437 (Smoking and tobacco cessation counseling visit for the asymptomatic patient; intensive, greater than 10 minutes).

CMS has advised its Medicare contractors to replace codes G0436 and G0437 with CPT codes 99406 (Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes) and 99407 (Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes). Additional information on Medicare coverage of such counseling is discussed in Section 210.4.1 of the Medicare National Coverage Determination Manual.

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

Friday, September 9, 2016

CMS will let you pick your pace for MACRA compliance

Apparently acknowledging criticism that the timetable for physicians to participate in the Quality Payment Program under the Medicare Access and CHIP Reauthorization Act (MACRA) next year may be too fast for some, the Centers for Medicare & Medicaid Services (CMS) is giving you some options.

In a blog post this week, Acting CMS Administrator Andy Slavitt laid out the four options, which let physicians and other providers pick the pace of their participation in the first performance period that begins Jan. 1. Choosing one of these options would ensure you do not receive a Medicare payment cut in 2019.

The first option is more of a test of the Quality Payment Program, allowing you to avoid the 2019 payment penalty if you submit at least some data after Jan. 1. The idea is that you will show your system is operating and prepared for broader participation in 2018 and 2019.

The second option is participating for part of 2017 as opposed to an entire calendar year. For example, Slavitt writes, you could submit data for a period starting later and Jan. 1 for quality measures, how your practice uses technology, and what improvement activities your practice is undertaking. and still qualify for a small payment bonus.

If your practice was already expected to be prepared to participate fully in the Quality Payment Program on Jan. 1, you can take option three, which has you submitting a full calendar year of data for the program and qualifying for a modest positive payment adjustment.

The final option is to ignore submitting quality data and other information entirely and join an Advanced Alternative Payment Model in 2017, as provided in MACRA. Physicians who meet the required level of Medicare payments or patients through this alternative model would qualify for a 5 percent incentive payment in 2019.

CMS will provide more details about these options and the Quality Payment Program in general when it releases its final rule on MACRA implementation by Nov. 1.  

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

Friday, August 19, 2016

CMS clarifies the new lab reporting requirement

Last month, we highlighted a new rule from Medicare that requires certain clinical labs to report how much they receive from private insurers for lab tests. Now, the Centers for Medicare & Medicaid Services (CMS) has issued guidance to help labs meet the new requirements by clarifying some of the who, what, and when related to the new rule.

With respect to “who,” labs can use a four-question test to determine if the new rule applies to them:

• Is the lab certified under the Clinical Laboratory Improvement Amendments (CLIA)?
• Does the CLIA-certified lab bill Medicare Part B under its own national provider identifier?
• Does the lab meet the majority of Medicare revenues threshold?
• Does the lab meet the low expenditure threshold?

To answer “what,” CMS lays out the three major types of information that affected labs must collect and report:

• The specific billing code associated with a test
• The private payer rate for each test for which final payment has been made during the data collection period
• The associated volume for each test

Finally, in terms of “when,” the guidance defines the first data collection and reporting periods:

• Labs affected by the rule must collect applicable information from all claims for which the lab received final payment between Jan. 1 and June 30 of this year.
• Labs must submit that information to CMS between Jan. 1 and March 31 of next year.

During the six-month window between the end of the data collection period and the beginning of the data reporting period, CMS expects laboratories and reporting entities to assess whether the applicable laboratory thresholds are met.

As noted in our original post, CMS estimates this new rule will include only 5 percent of physician office labs and about half of independent labs. For those that fall in that category, the new guidance is essential reading.

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

Thursday, August 4, 2016

Comprehensive Primary Care Plus regions announced

Back in April, the Centers for Medicare & Medicaid Services (CMS) unveiled its latest model of practice transformation and primary care delivery, Comprehensive Primary Care Plus (CPC+). This new model is available only for a limited time and in limited areas – but those areas have finally been announced.

CMS has selected 10 states (Arkansas, Colorado, Hawaii, Michigan, Montana, New Jersey, Oklahoma, Oregon, Rhode Island and Tennessee) and four more specific regions (the Greater Kansas City region in Missouri and Kansas, the North Hudson-Capital region of New York, a region covering all of Ohio and northern Kentucky, and the Greater Philadelphia region of Pennsylvania).

CMS chose these regions based on the 57 commercial payers who CMS selected to participate in the program and who wil support CMS’s payment model. A full list of participating payers by region can be downloaded on the CMS CPC+ webpage. CPC+ is expected to involve up to 5,000 practices and more than 20,000 physicians and other clinicians serving up to 25 million patients.

Individual physicians and practices in the designated regions can apply to participate through the CPC+ Online Application Portal through Sept. 15. Practice application questions can be found in the Request for Applications.

CMS is offering additional answers to CPC+ Practice Frequently Asked Questions and webinars called Open Door Forums focused on various CPC+ program topics. The AAFP is also partnering with Caravan Health to help practices prepare for the requirements of CPC+ through Caravan Health's Boot Camp.

Physicians participating in the five-year program, which is scheduled to begin Jan. 1, must choose one of two tracks focused on care management, access and continuity, planned care for population health, patient and family caregiver engagement, and care that is comprehensive and coordinated.

While Track 1 requirements are similar to the original CPC program’s milestones, Track 2 forces participants to push the envelope in terms of using health information technology, targeting patients with complex needs, and helping meet patients’ psychosocial 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.

— Kristen Stine, Practice Transformation Strategist for the American Academy of Family Physicians

Tuesday, July 19, 2016

CMS to calculate new payment rates for lab tests

If your practice has an office laboratory, a new final rule issued by the Centers for Medicare & Medicaid Services (CMS) may affect you.

The rule requires that certain clinical labs report how much they receive from private insurers for lab tests as well as lab test volumes. CMS plans to use this information to calculate new Medicare payment rates under the Clinical Laboratory Fee Schedule (CLFS), beginning in 2018.

Only labs that receive at least $12,500 a year in Medicare revenues from laboratory services paid under the CLFS and more than half of their Medicare revenues from laboratory and/or physician services will have to report.

CMS estimates this will include only 5 percent of physician office labs and about half of independent labs. However, the information provided by those labs will help revise Medicare payment rates for everyone.

Under the plan, the affected labs will collect payer data from the first six months of this year and report it to CMS between Jan. 1 and March 31 of next year. CMS will then calculate the new Medicare rates, based on a weighted median of private payers for each test, and post them in early November 2017. They will go into effect Jan. 1, 2018.

For more information, see the CMS press release and detailed fact sheet.

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

Friday, June 24, 2016

Make sure to recertify EIDM users by June 30

Time is running out if your practice hasn’t recertified its user accounts in the Enterprise Identity Management (EIDM) system. Letting those accounts lapse could complicate reviewing your Quality and Resource Use Reports (QRURs) later.

Individual practitioners and providers’ security officials (SOs) have until June 30 to log into the system and recertify who in the practice has the right to access the system. The Centers for Medicare & Medicaid Services (CMS) requires users to recertify annually. Failure to recertify user roles will result in those roles being revoked. Once revoked, the user must go through the process of requesting the role from the SO or individual practitioner again.

The SO and individual practitioners can log into the CMS Enterprise Portal using existing credentials and access the list of users who require recertification. The list is located under the “View and Manage Access” page under the “Annual Certification” link on the left-hand side of the screen. If you experience issues, you can contact the QualityNet Help Desk at 1-866-288-8912. The QualityNet Help Desk can also tell you who the SOs are for your Tax Identification Number (TIN).

Maintaining access to the EIDM system is critical for the QRUR. CMS releases a mid-year QRUR and an annual QRUR. The 2015 mid-year reports were released in April, while the 2015 annual reports will be available in the fall. These reports provide information on a TIN’s performance on cost and quality measures. Practices can use the QRUR to review their performance and identify areas where improvement may be needed. Reviewing today will help practices prepare for the implantation of the Medicare Access and CHIP Reauthorization Act (MACRA).

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

Tuesday, May 17, 2016

Small practices face potential headaches under MACRA

For solo and small physician practices, the recently published proposed rule for how the Centers for Medicare & Medicaid Services (CMS) plans to implement the Medicare and Children’s Health Insurance Program Reauthorization Act (MACRA) set off some alarm bells. According to the proposed rule’s regulatory impact analysis, 87 percent of solo practice clinicians who are eligible for the Merit-Based Incentive Payment System (MIPS) – one of two payment tracks under MACRA – will receive a penalty; for groups of two to nine clinicians, the percentage is almost 70 percent.

Responding to the concerns generated by this analysis, CMS has now issued a fact sheet that attempts to show it is sensitive to the unique challenges that small practices face in different types of communities. The fact sheet is also meant to show that the agency’s proposed implementation of MACRA, including MIPS and alternative payment models (APMs), provides accommodations for various practice sizes and configurations. Among the provisions that CMS highlights in its defense are:

• Clinicians or groups that have $10,000 or less in Medicare charges and 100 Medicare patients or fewer are excluded from the MIPS payment adjustment.
• When a practice is scored for MIPS, it will only be scored for categories where it has a sufficient number of applicable measures and activities.
• Small groups will have more flexibility within each of the MIPS performance categories. For example, CMS will calculate only two population measures based on claims data for solo physicians and groups of nine or fewer physicians instead of the three population measures required for larger groups under the quality performance category of MIPS.

CMS also notes that the proposed rule allows small practices or practices in rural or healthcare professional shortage areas to participate in the Advanced APM track – and receive incentive payments – by providing special rules for these practices to qualify as Advanced APMs under medical home models.  

Ironically, CMS plans to delay implementing one provision of MACRA specifically intended to help solo and small group practices succeed under MIPS. Specifically, MACRA allows MIPS-eligible professionals to combine into “virtual” groups to participate in the payment track. However, as noted in the fact sheet and the proposed rule, CMS will not make this option available until the second year of the program.

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

Thursday, May 12, 2016

Some help understanding the proposed MACRA payment reforms

Last month, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule that describes how CMS intends to implement the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). MACRA repealed the Medicare sustainable growth rate methodology with a new approach that pays clinicians for the value and quality of care they provide. The proposed rule would implement these changes through a unified framework called the “Quality Payment Program,” which includes two paths – the Merit-Based Incentive Payment System (MIPS) and the Alternative Payment Model (APM). Comments on the proposed rule are due to CMS by June 27.

In the regulation, CMS says it expects that most Medicare physicians will initially participate through the MIPS. The MIPS consolidates three existing programs, the Physician Quality Reporting System, the Physician Value-based Payment Modifier, and the Medicare Electronic Health Record (EHR) Incentive Program. MIPS will pay Medicare physicians for providing high value care through success in four performance categories:

•  Quality (50 percent of total score in year one): For this category, physicians would choose to report six measures from among a range of options.
•  Advancing Care Information (25 percent of total score in year one): For this category, physicians would choose to report customizable measures that reflect how they use technology in their day-to-day practice, with a particular emphasis on interoperability and information exchange. Unlike the existing reporting program, this category would not require all-or-nothing EHR measurement or redundant quality reporting. CMS created a summary specific to the Advancing Care Information category.
•  Clinical Practice Improvement Activities (15 percent of total score in year one): This category would reward clinical practice improvements, such as activities focused on care coordination, beneficiary engagement, and patient safety. Physicians may select activities that match their practices’ goals from a list of more than 90 options.
•    Resource Use (10 percent of total score in year one): For this category, the score would be based on Medicare claims, meaning no reporting requirements for physicians. This category would use 40 episode-specific measures to account for differences among specialties.

CMS would begin measuring performance for physicians and other clinicians through MIPS in 2017, with payments based on those measures beginning in 2019.

Under the APM pathway, MACRA authorizes incentives for physicians who take further steps towards care transformation. To qualify as an Advanced APM, an APM must 1) require participants to use certified EHR technology, 2) pay covered professional services based on quality measures comparable to those in the quality performance category under MIPS, and 3) mandate that participating APM entities bear risk for monetary losses of a more than nominal amount – or that the entity must assume risk for potential financial losses – under the APM. CMS proposes three dimensions of risk – marginal risk, minimum loss rate, and total potential risk – to determine if an entity meets the more than nominal risk standard. Medicare physicians who sufficiently participate in an Advance APM would be exempt from MIPS reporting requirements and qualify for a 5 percent Medicare Part B incentive payment.

CMS notes that physicians who participate to some extent in APMs may not meet the law’s requirements for sufficient participation in the most advanced models. But it says the proposed rule is designed to provide these clinicians with financial rewards within MIPS. CMS expects that the number of clinicians who qualify as participating in Advanced APMs will grow as the program matures.

As an alternative to reading the more than 900 pages of regulations, the CMS issued a press release and the Health and Human Services secretary published a blog post, which includes the video, “Delivery System Reform: Paying for What Works.”

Keep an eye on this space for additional information on MACRA as we more fully understand how this law will affect family physicians for years to come.

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

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

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