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Newsletter 2014 Q2

Changes for the 2014 Medicare Physician Fee Schedule

CMS's release of the 2014 Final Rule for "Revisions to Payment Policies under the Physician Fee Schedule, Clinical Laboratory Fee Schedule & Other Revisions to Part B for CY 2014" was just over 1,300 pages and included many regulatory updates. Below are some important provisions from the final rule that we have identified that may affect your practice.

Sustainable Growth Rate (SGR)
On April 1, 2014 President Obama signed into law the bill H.R. 4302, Protecting Access to Medicare Act of 2014, which provides a 12 month "patch" to avoid the 24% reimbursement cut providers would have faced according to the SGR formula. This gives Congress until March 31, 2015 to either provide a permanent fix for the SGR formula or issue another temporary fix. This bill also extended other Medicare and Medicaid provisions and delayed the adoption of ICD-10 for at least one year. To read the full text of the bill, click here.

Physician Fee Schedule Reimbursement Changes
The 2014 Physician Fee Schedule Final Rule included changes to reimbursement rates for Medicare Part B. These changes were based on changes to the Relative Value Units (RVU's) which include the Work, PE, and Malpractice RVU's. As part of the final rule, the Centers for Medicare & Medicaid Services (CMS) included a reimbursement impact analysis to assess the overall impact these RVU changes would have on allowed charges. The chart below summarizes the top five specialties negatively and positively affected by these changes in 2014.

The chart below summarizes the impact of these changes for specialties of many of Alta Partners' billing clients.

To download the full 2014 Physician Fee Schedule Final Rule with Comment Period, click here.

To learn more about how the changes may impact your practice, contact Lacy Sharratt, Healthcare Consultant, at lks@altapartnersllc.com or (440) 808-3644.

Chronic Care Management
Starting in 2015, CMS will begin making a separate payment for chronic care management service.

• New CPT Code
CMS's main concern is that current CPT E/M codes may not reflect all the services and resources required to furnish comprehensive, coordinated care management for certain categories of beneficiaries. Billing for separately payable chronic care management services will take place by utilizing the newly created G-code. CMS has yet to finalize the G-code, its usability, or its values. The comment and review period is expected to continue throughout the year, as the new G-code will not be put into practice until 2015. As always, Alta Partners will keep you informed when the final policy is implemented.

While the new G-code has not been finalized, CMS has released the code's description:
GXXX "Chronic care management services furnished to patients with multiple (two or more) chronic conditions expected t last at least 12 months, or until the death of the patient, that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; 20 minutes or more; per 30 days"

• New Service Standards
CMS standards for furnishing chronic care management services ensure that the physicians and practitioners who bill for these services have the capability to provide them. These standards include:

• Practice utilization of certified Electronic Health Records (EHR) with 24/7 remote access capability to all practitioners.
• Specialized advances practice registered nurse or physician assistant whose role is specifically scaled to meet the needs for beneficiaries receiving chronic care management services by the practice.
• The practice must be able to demonstrate the use of written protocols by staff participating in the furnishing of services that describe methods, norms, strategies, procedures, steps, approaches, guidelines, care plans, and patient education.

• Patient Consent Requirements
The eligible beneficiary must be informed about the availability of the services from the practitioner and provide his or her written agreement to have the services provided, including agreeing to the electronic communication of the patient's information with other treating providers as part of care coordination. This would include a discussion with the patient, and caregiver when applicable, about what chronic care management services are, how these services are accessed, how the patient's information will be shared among other providers in the care team, and that cost-sharing applies to these services even when they are not delivered face-to-face in the practice.
The agreement for chronic care management services could be revoked by the beneficiary at any time. However, if the revocation occurs during a current chronic care management 30-day period, the revocation is not effective until the end of that period. The beneficiary could notify the practitioner of revocation either verbally or in writing.

Application of Therapy Caps to Critical Access Hospitals (CAH)
According to CMS, outpatient therapy services furnished by a CAH should be treated consistently with outpatient therapy services furnished in all other settings. CMS established an increased therapy cap from CY 2013 of $1,900 to CY 2014 of $1,920. Therapy caps are established separately for Occupational Therapy (OT) and combined for Physical Therapy and Speech-Language Pathology (PT and SLP).

Since CY 2011, a therapy multiple procedure payment reduction (MPPR) policy has applied to the second and subsequent "always therapy" services billed on the same date of service for one patient by the same practitioner or facility under the same NPI. Prior to April 1, 2013, the therapy MPPR reduced the practice expense portion of office-based services by 20 percent and reduced the practice expense portion of institutional-based services by 25 percent. As of April 1, 2013, therapy MPPR increases to 50% for all outpatient therapy services. For a full list of the 2014 "always therapy" codes click here.

For more information
If you have questions regarding the changes to the 2014 Physician Fee Schedule contact Tami Maust, our in-house trainer and coding specialist, at tjm@altapartnersllc.com or (440) 808-3662.


Ohio Department of Medicaid changes to Medicare Part B cost sharing reimbursement

On December 30, 2013 the Ohio Department of Medicaid (ODM) released transmittal letter MHTL 3334-13-10 detailing changes to the Medicare Part B cost sharing reimbursement methodology. Effective January 1, 2014, Part B Rule 5160-1-05.3 has been amended to allow the ODM to pay the lesser of the following for Part B cost sharing for services other than physician services:

• The sum of the deductible and coinsurance Medicare ODM is obligated to pay for crossover claims; or
• The difference between the Medicare approved amount and the sum of the amount Medicare paid and all other third party (insurance other than Medicare or Medicaid) payments; or
• Except for physician services, the difference between the sum of the amount Medicare paid and any third party payments, and the Medicaid maximum allowable reimbursement rate for the same identified service or services.
This eliminates additional payments by Medicaid for dual eligible Medicare/Medicaid patients by allowing the ODM to reimburse up to the Medicaid maximum amount if using this amount results in a lower payment when compared to the full Medicare cost sharing amount.

For more information on the changes and how they may affect your practice, contact Jennifer Dalton at jad@altapartnersllc.com or (440) 808-3706.


PQRS Checkup: FAQs on the Medicare Quality Reporting Initiative and What You Need to Know

We wanted to make sure that all of Alta Partners' clients were aware of the Medicare PQRS program and understand how it will affect your practice not only this year, but also in years to come, based on what you are doing today. If you currently participate in PQRS, double check your practice activities to see how they compare to current program requirements. Call Lynn Bolin, Director of EHR, at (440) 808-3703 with any questions you may have.

1. What is PQRS?
The Physician Quality Reporting System (PQRS) is a voluntary pay-for-reporting initiative for health care providers who render care to Medicare beneficiaries. Eligible professionals include physicians, physician assistants, nurse practitioners, clinical social workers, and other mid-level clinicians. PQRS measures quality of clinical practices using defined quality metrics. Providers report performance to CMS, which establishes whether the reporting threshold was met and distributes incentive payments accordingly. Though, at its inception, the PQRS was based solely on claims submission, CMS expanded reporting options that offer providers multiple methods of reporting across defined periods.

2. What are the benefits for PQRS participants?
The PQRS offers financial incentives for provider participation in the expectation that the documentation will promote clear standards for quality clinical outcomes. Providers who properly reported their 2013 clinical quality measures (CQM) on or before February 28, 2014, will receive an incentive payment equal to 0.5% of the physician fee schedule (PFS). In addition to the incentive payment, professionals who met the reporting requirements in 2013 will avoid the 2015 penalty and will receive the full PFS amount for services furnished in 2015. If you are not currently participating in PQRS, you need to be. If you do not participate in 2014, you not only miss out on the 0.5% incentive payment but also risk the 2.0% penalty in 2016.

3. What is the penalty if I don't participate?
Eligible professionals who did not satisfactorily report quality data in 2013 will be subject to a downward payment adjustment applied to the PFS amount for covered professional services furnished by the eligible professional during 2015. Financial penalties for nonparticipation in the program will be introduced in 2015 with a −1.5% payment adjustment to the PFS (based on 2013 participation) that will be increased to −2% in 2016 and subsequent years. This means providers subject to the adjustment will receive only 98.5% of the fee schedule amount in 2015 and 98% of the fee schedule in 2016 and each subsequent year. Payments are on a two-year long cycle, with penalties for not satisfactorily reporting in 2013 taking effect in 2015, and so forth.
The financial impact of the penalty on the practice will vary depending on what percent of claims are paid through Medicare (payer mix). Let's use a practice subject to the 1.5% payment reduction in 2015 with $250,000 in reimbursements as an example. If the Medicare mix is low, say 10%, the practice would estimate a $375 reduction in reimbursements ($250,000 x 10% x 1.5%). If the payer mix is slightly higher at 25%, the practice would see a $938 reduction in reimbursements. Looking at a higher Medicare mix of 40%, the estimated payment reduction would be closer to $1,500. The higher the Medicare mix, the higher the potential reduction in reimbursements.

4. How can I avoid a penalty?
For the 2013 program, the registration deadline was October 18, 2013 with a documentation submission deadline of February 28, 2014. Eligible professionals that did not participate in 2013 are still able to participate in the 2014 program. Those participating in the 2014 PQRS program will be eligible to receive the 0.5% incentive payment and avoid the 2.0% penalty in 2016.

Individual eligible professionals do not need to sign-up or pre-register in order to participate in PQRS. Those participating under the Group Practice Reporting Option (GPRO) must register during the registration period, April 1, 2014 - September 30, 2014. To determine eligibility for reporting under GPRO, please see the CMS Group Practice Reporting Option 2014 Requirements document. The next step is to determine which reporting method is best and which measures apply to your practice.

The data submission deadline for the 2014 PQRS program is February 27, 2015. While that is just under a year away, it is important that your practice prepare now to ensure the measurement requirements are fully understood and you are able to produce and submit the required EHR reporting files.

5. How are the quality measures calculated?
Measures consist of a denominator and numerator. PQRS denominators describe the eligible cases for each measure, such as the eligible patient population associated with a measure's numerator. The numerator describes the clinical action required by the measure for reporting and performance. Each component is defined by specific clinical codes described in each measure specification along with reporting instructions.

6. How do I know what and where to report?
Check out these flowcharts to see which one applies to your practice.

Measure Applicability Validation

7. I already have an EHR system. Can I use it for PQRS purposes?
Yes! You must participate in both EHR and PQRS programs. You can submit information on beneficiary sample through your Office of the National Coordinator for Health Information Technology (ONC)-certified EHR, PQRS-certified system to meet the core objectives of the incentive program; at the same time, keep reporting all meaningful use data through the EHR attestation system. Remember to indicate within the EHR system that your practice participates in the PQRS-EHR incentive program. Also, make sure you keep all reporting dates aligned with CMS (for example, reporting year is a full calendar year from January 1st to December 31st, and data is submitted no later than February 27 of the following year). Call Lynn Bolin at (440) 808-3703 with questions as to whether your system is certified.

8. Does participating in PQRS really improve quality of?
Studies have yet to show that participation in any pay-for-performance program results in improved health outcomes. As a set of mainly process measures, PQRS metrics do not measure quality of care during the full cycle of care, as would be required by future Accountable Care Organizations. Instead, the focus is on measures based on an individual patient care visit. With that being said, providers should view PQRS participation as a means for public reporting of better performance that could yield additional patient volume.

9. What can I do to streamline the PQRS implementation?
Leadership support cannot be overstated. Encouragement from administration is crucial to continued program participation and success. Meet frequently with your team to discuss benefits and limitation of the programs, and allow them room to discuss frustrations and propose improvements. Try to streamline the implementation process by flagging cases that are eligible for measures reporting by implementing an edit in your practice's billing software so that you must enter quality data codes (QDCs) before final submission. The edit then could flag claims based on a combination of codes.

Lynn can help! Alta Partners' Director of EHR, Lynn Bolin, can help ensure that your PQRS program is being properly operated and that your practice is prepared to meet the current and future program requirements.

10. Where else can I get information about PQRS?
Talk with our Director of EHR, Lynn Bolin, and learn about our experience with implementing PQRS at other practices and how we can help with yours. You can contact Lynn at (440) 808-3703 or at nlb@altapartnersllc.com.