Gastroenterology Coding Alert

These measures are a means to meet your MIPS minimum and potentially reap a bonus in 2019.

MIPS is one of the single largest overhauls to Medicare since its inception, and months after its announcement many physicians find themselves scratching their heads about how to participate. Or, in some cases, whether they should participate at all.

However, the requirements for the 2017 reporting year (which is the 2019 reimbursement year) are fairly easy to meet. Below we discuss what you can do in 2017 to begin meeting and even exceeding the measures for MIPS.

To participate, or not to participate? That is … a really good question.

2017 is the trial year for MIPS, and many physicians are on the fence about participating in the program because change can be difficult to implement and the initial penalty is only 4 percent and it does not apply for two years, confirms Michael Weinstein, MD, president & CEO of Capital Digestive Care, Silver Spring, Md.

Headcount: CMS estimates there are roughly 12,600 eligible GI clinicians in 2019 that would be subject to MIPS and that there will be 1,849 GI clinicians excluded from MIPS in 2019.

Note, MIPS does not apply to hospital reimbursement or impact ASC facility fees. Eligible clinicians can fulfill MIPS requirements as an individual or as part of a group, and even APM-participating clinicians need to report through MIPS in 2017. “Those few participating in an Advanced APM at a significant portion of their total Medicare revenue might avoid MIPS participation,” advises Weinstein.

Ease of participation for GI lends an advantage over other specialties

For GI, CMS estimates that roughly 62 percent would be eligible for a bonus and 38 percent would be subject to a payment cut. Thus, there must be a higher ratio of low scoring providers in other specialties. Considering that 60 percent of podiatrists, for example, polled by Podiatry Management said they’ll either not participate at all or submit the minimum measures in 2017, this offers opportunity for GIs.

“A lot of people decided to forego efforts in Meaningful Use, because no one is getting to Stage 3,” said Mark Dollard, DPM, DABPS, FACFAS of Loudoun Foot and Ankle in Sterling, Va. Why? Getting to MU Stage 3 is practically impossible because EHRs aren’t yet truly interop­erable and they don’t communicate, he explains. “People have soured on these programs because they aren’t receiving the incentives initially promised to them for their efforts.”

For some physicians to win, some must lose. It’s important to remember that MIPS is “budget neutral”, and this is CMS we’re talking about here. Since you’re being graded on a curve, take advantage of the easy pickings.

Big practice advantage: “Larger GI practices with sophisticated EHR systems and with dedicated quality improvement staff will find participation in MIPS a less burdensome work flow change,” says Weinstein. “AttheAt the heart of this is the opportunity to gain a bonus for very high performance (the top 5 percent of scores)--and that bonus could be substantial, given that the law permits a total of $500 million to those deemed high achievers within the MIPS scoring ranks.”

And the bottom line is that it’s inexorable

MIPS is independent of the Affordable Care Act, and so any upheaval from the ACA’s potential repeal will not affect it. MIPS may be a hassle, but it’s inevitable. It will take an act of Congress (literally) to change and you’re required to participate if you want to maintain optimal levels of Medicare reimbursement.

Fortunately, while you’re weighing pros and cons during 2017, you can easily meet the threshold.

And you may be excluded from the participation requirement if:

• You have Medicare billing charges less than or equal to $30,000 or provide care to 100 or fewer Part B enrolled Medicare beneficiaries in one of the two determination periods

               o 9/1/2015 to 8/31/2016
               o 9/1/2016 to 8/31/2017

• You are a newly Medicare eligible clinician. This includes individual physicians in your practice.
• You are a qualified APM participant​

               o Note, even APM participants will need to submit through MIPS in 2017.

The minimum thresholds for 2017 and where they come from

CMS ranks your MIPS performance from 0 to 100. The Performance Threshold is set at 3 and the Exceptional Performance Threshold at 70. This means that any clinician with a score of at least 3 will avoid a negative adjustment, while those scoring 70 or higher will be eligible for an Exceptional Performance Adjustment from the $500 million pool. The range of penalties and bonuses in the years are:

2019: +4 percent to -4 percent, based on your 2017 score
2020: +5 percent to -5 percent, based on your 2018 score
2021: +7 percent to -7 percent, based on your 2019 score
2022: +9 percent to -9 percent, based on your 2020 score

Here are the factors you need to focus on in 2017. Resource Use (or cost) will be 10 percent of the score’s weight in 2018 and moving forward, but the final rule removed it from 2017. To avoid the penalty, you can simply report one quality measure, one clinical practice activity, or report the five ACI measures

Quality measures replace PQRS, will be 60 percent of the 2017 score’s weight

To meet the full requirement for the maximum 60, you must report six measures, including a cross-cutting measure. One of those must be an outcome measure if possible, which for gastroenterology would be:

• Screening colonoscopy adenoma detection rate: the percentage of patients age 50 years or older with at least one conventional adenoma or colorectal cancer detected during screening colonoscopy. “Participating in a registry that tabulates procedure processes and outcomes (such as GIQuIC sponsored by ASGE and ACG) would be needed to report this measure,” advises Weinstein.

High-priority measures are worth bonus points for the Quality Performance Category, but reporting them is optional if you report an outcomes measure. This makes it a smart idea to include as many high-priority measures as possible in your six Quality Performance Category Measures. Here’s a list of recommended measures:

• Hepatitis C: discussion and shared decision making surrounding treatment options
• Age appropriate screening colonoscopy
• Colonoscopy interval for patients with a history of adenomatous polyps – avoidance of inappropriate use
• Biopsy follow-up
• Closing the referral loop: receipt of specialist report
• Elder maltreatment screen and follow-up plan
• Documentation of current medications in the medical record
• Pain assessment and follow-up
• Use of high-risk medications in the elderly
• Appropriate follow-up interval for normal colonoscopy in average risk patients

Take note that the measures must all be reported through the same mechanism, whether it’s EHR, claims reporting, or registry reporting.

You can report your quality measures through a qualified clinical data registry (QCDR) like you did with PQRS, such as GIQuIC. In fact, you’ll get points for clinical practice improvement activity (CPIA) points for partici­pating in one. The final list of approved QCDRs will be announced in May 2017.

Advancing Care Information replaces Meaningful Use, will be 25 percent of 2017’s score

The emphasis for ACI is on interoperability and information exchange, major criticisms of MU. You will need to report on five measures for the 90-day period to avoid a penalty, but can report up to nine for extra credit. Here are the five to focus on to avoid the penalty:

• Security Risk Analysis
• e-Prescribing
• Provide patient access
• Send summary of care
• Request/accept summary of care

Clinical Practice Improvement Activities will be 15 percent

CPIA focus on patient engagement, care coordination, and patient safety. For the full 15 points, you must engage in four activities. The bright side is that there are 90 to choose from. You can report on just one of these to avoid the penalty in 2019. Here are examples of easy ones to implement:

• Participate in a QCDR
• Register in your state’s prescription drug monitoring program
• Develop a program to send reports back to referring physicians
• Consult the prescription drug monitoring program
• Assess patient experience of care through surveys, advisory councils and/or other mechanisms.
• Engagement of patients, family and caregivers in developing a plan of care
• Implementation of condition-specific chronic disease self-management support programs

How you participate is up to you

To avoid the penalty, you can simply report one quality measure, or one clinical practice activity, or report the five ACI measures. And there’s support available for GI practices trying to get this right. “The national gastroen­terology societies are all paying close attention to identify options for members to successfully participate in MIPs and to gather stories of those unable to achieve sufficient scores,” says Weinstein.

You can participate for part of the calendar year to avoid a negative payment adjustment and possibly qualify for a small positive payment adjustment. You could potentially earn a full positive adjustment from just those 90 days.

• Report for a minimum of 90 consecutive days
• Report more than one quality measure or more than one clinical practice improvement activity, or more than 5 measures of ACI

For full participation that can max your score out at 100, you’ll need to report the following for 90 days to one year:

• Six Quality Measures
• Two to four CPIA
• Five ACI Measures.