Check Remittance Advice for MIPS Payment Adjustments

Check Remittance Advice for MIPS Payment Adjustments

With this being the first payment year of the Merit-based Incentive Payment System (MIPS), MIPS eligible clinicians and clinician groups should start tracking payment adjustments in their Medicare Part B claims. Billing staff also may want to prepare for questions from patients who are privy to the information.

Lots at Stake

Based on performance in MIPS in 2017, MIPS eligible clinicians and clinician groups can expect to see somewhere between +/- 4 percent payment adjustments in their Medicare Part Claims. This adjustment is in addition to the automatic 0.5 percent update to the single conversion factor.

Information about MIPS payment adjustments appears on Remittance Advice (RA), as well as Medicare Summary Notices (MSNs).

Take Action

Solo and group practices with MIPS eligible clinicians should implement a system of checks and balances to track and ensure the accuracy of their clinicians’ MIPS payment adjustments to Medicare Part B claims. For example:

  1. Review the RA when you submit a claim. Medicare Administrative Contractors use three code types to communicate information about MIPS payment adjustments:
    1. Claim Adjustment Reason Codes (CARCs), which provide financial information about claims decisions.
    2. Remittance Advice Remark Codes (RARCs), which further explain an adjustment or other information not expressed by a CARC.
    3. Group Code, which identifies the general category of payment adjustment.

If a positive MIPS payment adjustment has been applied to a claim, the following codes will appear on the RA:

  • CARC 144 Incentive adjustment
  • RARC N807 Payment adjustment based on MIPS
  • Group Code CO Indicates a contractual agreement between payer and payee, or a regulatory requirement, resulted in an adjustment

If a negative MIPS payment adjustment has been applied to a claim, the following codes will appear on the RA:

What is Macra

  • CARC 237 Legislated/Regulatory Penalty
  • RARC N807 Payment adjustment based on MIPS
  • Group Code CO Indicates a contractual agreement between payer and payee, or a regulatory requirement, resulted in an adjustment
  1. Flag adjusted claims to track total revenue lost or gained by MIPS. This will be essential information in determining things such as whether the benefits of MIPS participation outweigh the costs.
  2. Create a blanket statement for patient inquiries. Original Medicare beneficiaries will be notified in their quarterly MSNs whether a clinician’s payment for a service they received was adjusted under MIPS. The MSN will state, “This claim shows a quality reporting program adjustment.”
    1. One solution for inquiring minds is to create a handout that explains the adjustment in simple terms. For example:

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) required the Centers for Medicare & Medicaid Services (CMS) to implement the Quality Payment Program, which adjusts eligible clinicians’ Medicare Part B reimbursements based on their ability to follow clinical guidelines for value-based care. Your clinician is receiving payment adjustments based on his/her performance in this program. Quality reporting program adjustments do not affect patient charges.

Or something to that effect. Best practice would be to have your organization’s attorney and/or compliance manager approve the statement for use.

Renee Dustman
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Renee Dustman

Executive Editor at AAPC
Renee Dustman, BS, AAPC MACRA Proficient, is an executive editor at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. Renee has more than 20 years experience in print production and content management. Follow her on Twitter @dustman_aapc.
Renee Dustman
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About Has 707 Posts

Renee Dustman, BS, AAPC MACRA Proficient, is an executive editor at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. Renee has more than 20 years experience in print production and content management. Follow her on Twitter @dustman_aapc.

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