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Friday, September 30, 2016

See if you’re due a penalty in the 2015 PQRS physician feedback report

Individual physicians and groups can now access their 2015 Physician Quality Reporting System (PQRS) Physician Feedback reports, which provide valuable information about your practice and whether you will face a Medicare penalty in 2017.

Physicians can access the reports through the CMS Enterprise Portal. Users must have an Enterprise Identity Management (EIDM) account with the appropriate role to access the reports. You can also access your Quality and Resource Use Reports (QRUR), which were also recently released, through the same portal.

The Physician Feedback reports will provide the determination on whether you met the PQRS criteria to avoid a 2 percent negative payment adjustment in 2017. Information is available for all measures reported by your National Provider Identifier (NPI) for each reporting method. You can review if your successfully reported all your measures and see a brief rationale for any payment adjustment, such as insufficient measures reported. It also includes reporting rate and performance rate percentages.

You can file an informal review request if you feel the negative payment adjustment was an error. The informal review period is open until Nov. 30. Reviews can be filed through the Quality Reporting Communication Support Page. For more information or additional questions, contact the QualityNet Help Desk at qnetsupport@hcqis.org or (866) 288-8912. A Feedback Report User Guide is available online.

The Centers for Medicare & Medicaid Services will mail out payment adjustment notification letters at a later date. Accessing the Physician Feedback reports now will allow you to review your performance and file an informal review before the deadline.

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

Wednesday, September 28, 2016

QRUR reports for 2015 now available

The 2015 annual Quality and Resource Use Reports (QRUR) are now available to all group practices and solo practitioners. The report released by the Centers for Medicare & Medicaid Services (CMS) provides data on a practice’s performance on quality and cost metrics. The QRUR also provides information on how the practice fared under the 2017 Value-Based Payment Modifier (VBPM).

Authorized representatives can access the QRUR through the CMS Enterprise Portal with their Enterprise Identity Data Management (EIDM) credentials. You must have the correct role within the EIDM to access the report. CMS has provided guides on obtaining an EIDM account and how to obtain a QRUR.

Physicians will find in the reports performance information on the measures they submitted to the Physician Quality Reporting System (PQRS). CMS also calculates several claims-based quality and cost measures. Along with the QRUR, you can download an Excel file containing provider- and patient-level data. The information provided in the spreadsheets allows physicians to identify areas for improvement in cost and quality performance.

In 2017, all solo- and group-eligible professionals will be subject to the VBPM. Payment adjustments for the VBPM depend on practice size. It is important to review the information in the QRUR for accuracy. If you feel you have been assessed a payment penalty incorrectly, you can file an informal review through Nov. 30. You can submit a review through the CMS Enterprise Portal, or you can contact the Physician Value Help Desk at pvhelpdesk@cms.hhs.gov or 888-734-6433 (select option 3). The help desk is available by phone Monday-Friday 8 a.m.-8 p.m. EST.

Becoming familiar with the QRUR now is important as it will continue in some form under the Medicare Access and CHIP Reauthorization Act (MACRA). MACRA's Merit-Based Incentive Payment System (MIPS) incorporates elements of PQRS and the VBPM. The initial performance period is slated to begin in 2017.

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

Tuesday, September 27, 2016

Survey shows troublesome practice environment could affect patient access

Negative opinions about the state of medicine has large numbers of physicians planning to change their practices in ways that would decrease access to patients, according to a new study by The Physicians Foundation and Merritt Hawkins.

Almost half of the more than 17,000 physicians surveyed this spring said they planned over the next one to three years to cut back on hours worked, retire, take a non-clinical health care position, switch to a cash-only practice, or take other steps that would ultimate reduce access to patients.

"(The survey) reveals a physician workforce that continues to be dispirited about the current state of the medical profession and apprehensive about its future, due primarily to the large regulatory burden physicians face and the perceived erosion of their clinical autonomy," the researchers said in the report.

Overall, only 52 percent of physicians said they planned to remain working at the same level they are now. That represents a decline from 2014 when 56 percent of physicians surveyed said they didn't plan to change their practice.

The reasons for the negative changes are widespread. Almost 63 percent of respondents said they felt either "very" or "somewhat" pessimistic about the future of medicine, which was an increase from 51.1 percent in 2014. Eighty-one percent of physicians said they were overextended or at full capacity and unable to see more patients.

That said, many physicians aren't ready to abandon medicine entirely. Almost 72 percent of respondents said they would choose medicine as a career again, compared with 71 percent in 2014 and 67 percent in 2012. When asked if they would still recommend medicine as a career to their children or other young people, 51 percent said they would, up slightly from 50 percent in 2014.

Primary care physicians were a little more optimistic than their specialist peers, with 50.5 percent saying they are very or somewhat positive about the current state of medicine and 42.5 percent positive about the future of medicine. By comparison, 43.5 percent of specialists were positive about the present and 33.9 percent were positive about the future of medicine. Almost 73 percent of primary care physicians said they would choose medicine again as a career, compared with 71.4 percent of specialists, and 54 percent of primary care physicians said they would recommend medicine as a career to young people, compared with 50 percent of specialists.

The demographics of those responding to the survey showed the continuing trend of physicians leaving private practice for employed positions. Almost 33 percent characterized themselves as practice owners while about 58 percent said they worked for a hospital or large medical group. By comparison, 35 percent identified as practice owners in 2014 and 53 percent worked for large health groups and hospitals.

Looking at specific pieces of health care reform, only 43 percent said they were paid based on quality or value and 80 percent professed little knowledge of the Medicare Access and CHIP Reauthorization Act (MACRA). Only 11 percent of respondents said electronic health records have improve their interactions with patients, and only between 5 percent and 6 percent said the year-old ICD-10 coding has improved efficiency and revenues.

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

Thursday, September 15, 2016

Grace period for ICD-10 coming to an end

We’ve almost completed a full year of ICD-10-CM use. Congratulations! The world didn’t stop turning on its axis; the sun didn’t explode. Now, we are ready for the next hurdle related to ICD-10: The end of the “grace period” extended by the Centers for Medicare & Medicaid Services (CMS).

What was the “grace period?" It was a 12-month period, beginning Oct. 1, 2015, during which CMS processed and paid any Medicare claim submitted with a valid ICD-10 code that was at least within the family (the first three digits) of the diagnosis in question. This period is ending Sept. 30 of this year, after which CMS and its contractors will require the diagnostic codes you submit to reflect documentation and be specific to the patient and condition.

What codes should you be wary of using? “Unspecified,” “NOS,” and “not otherwise specified” codes will gain particular scrutiny from CMS. These codes will often have the digit “9” as the fourth or sixth character.  

How do you determine if your coding is safe? This answer is a two-parter. First, you need to evaluate which ICD-10 codes you are submitting most often on your claims. When I was in clinic, my family doctors thought they used certain codes often. But after I ran reports to show which ones they actually used, they were often surprised. Running a report of your top 25, 50, or 100 ICD-10 codes will help you determine how often you are using unspecified codes and where you need to concentrate on being more specific. Second, make sure you monitor your Medicare administrative contractor’s Local Coverage Determination (LCD) policies and CMS’s National Coverage Determination (NCD) policies. These polices list the covered diagnoses for specific services you may be performing, ordering or referring. Familiarize yourself with these policies. It will save you and your staff time and heartaches – and maybe a few claim denials, too.

Where can I go to learn more? CMS has published frequently asked questions and other resources about ICD-10.

– Barbie Hays, CPC, CPMA, CPC-I, CEMC, Coding and Compliance Strategist 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, September 2, 2016

Understanding what Medicare expects when ordering diabetes supplies

Sometimes, it’s not about getting paid. Sometimes, it’s about getting your patients what they need with the least amount of hassle and paying yourself with the time saved.

One of the ongoing sources of frustration for family physicians is helping their Medicare patients with diabetes receive the testing supplies they need to help manage their condition. Physicians have to continually order refills even though they know the patients will need to test for the rest of their lives and have to specify the brand name of the products they are ordering even though, from a clinical standpoint, the name of the brand doesn’t matter. Apparently, “diabetic testing supplies” is inadequate for Medicare purposes.

So, what do the Medicare administrative contractors (MACs) that process claims for glucose monitors and related supplies (e.g. lancets and test strips) expect from physicians? One of the MACs recently attempted to address that question.

For glucose monitors, Medicare requires the following prior to delivery by a supplier:

•    A face-to-face visit with the prescribing practitioner within six months before prescribing, including documentation that the patient was evaluated, treated or both for diabetes mellitus supporting need for the glucose monitor ordered,
•    An order that includes:
     o    Patient name
     o    Item ordered
     o    National Provider Identifier
     o    Date of the order
     o    Prescribing practitioner signature

Other diabetes testing supplies, such as test strips and lancets, require a detailed written order to the supplier. The detailed written order must contain:

•    Beneficiary's name
•    Prescribing practitioner’s name
•    Date of the order
•    Detailed description of the item(s)
•    Frequency of use or testing
•    Quantity to be dispensed
•    Number of refills
•    Prescribing practitioner’s signature and signature date

Be aware that there are limits to the quantity of test strips and lancets that Medicare covers when the basic coverage criteria are met. For beneficiaries treated with insulin, this limit is 300 every three months. For beneficiaries not receiving insulin, the limit is 100 every three months.

Medicare will cover quantities above these limits, but you have to document additional criteria in your patient’s medical record and be prepared to make that documentation available upon request. These additional documentation requirements are that you have seen and evaluated the beneficiary’s diabetes within six months of ordering supplies in excess of the normal amounts and have documented in the medical record the specific reason for the additional supplies. Also, you need:

•    Medical records documenting frequency of actual testing by beneficiary;
•    Specific narrative that documents frequency beneficiary is actually testing; or
•    Copy of the beneficiary’s testing log (must be provided to physician by beneficiary).

This guidance will not solve all of the hassles associated with getting your Medicare patients with diabetes the testing supplies they need. However, if it helps you get your patients the items they need faster, then so much the better for you, them, and Medicare. 

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

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