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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 11, 2016

It’s not too early to prepare for diagnosis code changes

Changes are coming to the ICD-10-CM code set. Effective with services provided on or after Oct. 1, ICD-10 diagnosis codes will update to the 2017 version.

The update will affect some of the diagnosis codes used in family medicine. For instance, one of the most significant changes is the addition of a new code, R73.03, for “Prediabetes.” Another example is coding for “familial hypercholesterolemia.” If you had to code that today, you would use E78.0 (Pure hypercholesterolemia). The 2017 version of ICD-10 replaces E78.0 with two new options:

•    E78.00 (Pure hypercholesterolemia, unspecified)
•    E78.01 (Familial hypercholesterolemia)

Similarly, ICD-10 is adding three new codes to report joint pain in the hands:

•    M25.541 (Pain in joints of right hand)
•    M25.542 (Pain in joints of left hand)
•    M25.549 (Pain in joints of unspecified hand)

These are just some of the changes relevant to family medicine. Crosschecking the diagnosis codes you use most often (e.g., the ones listed on your superbill) against the 2017 ICD-10-CM code set would be a good place to start in preparing for the update.

You can access the new ICD-10 code set and other related resources through the Centers for Medicare & Medicaid Services ICD-10 web site. The American Academy of Family Physicians also has ICD-10 resources on its web site, including AAFP Coding Flashcards for 2017.

Diagnosis code changes are coming. Are you ready?

– 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

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