ED Coding and Reimbursement Alert

15 potential ED measures listed in the DRAFT release, but you need only report 6 in 2017.

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) final rule released in the fall of 2016 will determine the programs for reporting during 2017. Is your ED ready?

MACRA is the law that repealed the Sustainable Growth Rate (SGR) Formula and changed the way that Medicare rewards clinicians for value over volume. The 2017 MACRA final rule streamlines multiple quality programs under the new Merit-Based Incentive Payments System (MIPS). It also provides bonus payments for participation in eligible alternative payment models (AMPs), says Michael A. Granovsky, MD. FACEP, CPC, President of LogixHealth, a national ED coding and billing company based in Bedford, MA.

MACRA is streamlining the former quality and value programs of the Physician Quality Reporting System (PQRS), the Value-Based Payment Modifier (VBM) and the Medicare EHR incentive program (Meaningful Use) into the Merit-Based Incentive Payment System (MIPS). For a successful 2017 you'll need to know how the MACRA final rule defines and scores those activities.

Who Can Participate?

Eligible providers are those who have Medicare Part B billings of over $30,000 a year and see over 100 Medicare patients annually. The term "provider" includes physicians, physician assistants, nurse practitioners, clinical nurse specialists, and nurse anesthetists

Who is excluded?

The Centers for Medicare & Medicaid Services (CMS) released in the final rule steps to address concerns regarding the ability of small or rural practices to participate. Physicians and related professionals who accrue less than or equal to $30,000 in Medicare Part B allowed charges or see less than or equal to 100 Medicare patients are exempt from MIPS requirements. Newly enrolled clinicians and those participating in advances Alternative payment methodologies (APMs) are also excluded from MIPS requirements, Granovsky says.

Incentive Payments Are Budget Neutral

Your future payments will be based on the MIPS composite performance score, which will result in a positive, negative, or neutral adjustments up to the percentages established in progressive coming years.

Take note: MIPS adjustments are budget neutral, so any bonus money available will come from penalties incurred by providers who did not report successfully. A scaling factor may be applied to upward adjustments to make total upward and downward adjustments equal. Additionally, there is a provision for an additional $500 million bonus pool for "exceptional" performance.

Remember that your 2017 reporting will impact your 2019 adjustments, Granovsky says. CMS has established the following incentive adjustments for the coming years:

• 2019 - plus or minus 4 percent
• 2020 - plus or minus 5 percent
• 2021- plus or minus 7 percent
• 2022 and beyond - plus or minus 9 percent

What Does that Mean in Real Terms for an ED Group?

Consider this example for the MIPS impact on an emergency medicine group that has volume of 40,000 patients a year with 22 percent of their volume Medicare patients assuming payments of $140 per encounter:

At the 4 percent Bonus Calculation: 40,000 X .22 X $140 X 4% = $49,280

If you had seven partners in the group the penalty or bonus would be about $7,000 for each partner.

In 2021 with a 7 percent Adjustment (based on 2019 data):

40,000 X .22 X $140 X 7%= $86,240 or about $12,320 per partner in penalty or bonus.

MIPS Categories and Weighting Evolution

The final rule outlines scoring as statutorily specified for four quality domains. Domain scoring weights for 2017 are noted parenthetically:

• Quality Activities (60 percent). CMS established that for full performance, clinicians will report on six quality measures and may pick from one specialty-specific or subspecialty-specific measure set.
• Clinical Practice Improvement Activities (15 percent). CMS finalized that eligible clinicians may attest to having completed up to four medium-weighted or two high-weighted clinical practice improvement activities, a reduction from the initially proposed six.
• Advancing Care Information Performance Category (25 percent). Eligible clinicians are required to report on five EHR use-related measures, a reduction from 11 measures in the proposed rule. CMS notes that "based on significant feedback, this area is simplified into supporting the exchange of patient information and how technology specifically supports the quality goals selected by the practice."
• Cost/Resource Use (Zero percent). CMS simplified the cost performance category and eliminated it from the calculation of providers' overall performance score for CY 17. CMS added that, as performance feedback » becomes available from claim analysis, the cost category's contribution to the overall performance score will increase to the statutory 30 percent level by 2021.

*The ACI is for all providers, but hospital-based have certain exceptions

Hospital Based Providers Get an Exemption

Section 1848(a)(7)(D) of the Act exempts hospital-based eligible providers (EPs) from the meaningful use payment adjustment. The final rule states, "We defined a hospital-based EP (eligible provider) as furnishing 75% of his/her services in sites of service identified as an inpatient hospital or emergency room in the year preceding the payment year, Claims with Place of Service Codes 21 (inpatient hospital) or 23 (emergency department) are considered hospital-based." That will include most providers in the ED setting, Granovsky says.

2017 Cost Category Final Rule Weighting

CMS has made a change for 2017 in the weighting of the cost category. "We believe that a transition period would be appropriate; we are lowering the weight of the cost performance category for the first and second MIPS payment years. We are finalizing a weighting of 0 percent for the transition year and 10 percent for the second MIPS payment year," CMS says in the final rule.

This change results in the following final hospital based Category weighting: