General Surgery Coding Alert

Get ready for VBPM, too. 

If you haven’t sorted through the quality-measure alphabet soup — PQRS, VBPM, QRUR — your general surgery group could lose big pay in the coming years. That’s because the bonuses turn to penalties the longer you don’t participate.

Check out the following “look back” and “look ahead” to see where your practice stands, and what you can do to prepare for the coming “pay-for-performance” world.

PQRS — Yesterday, Today, and Tomorrow

The Physician Quality Reporting System (PQRS) began as a totally voluntary initiative in 2007 to “support new payment systems that provide more financial resources to provide better care, rather than simply paying based on the volume of services,” according to CMS.

By 2015, the carrot of the “voluntary” program turned to a stick for eligible parties, with negative 1.5 percent adjustments (penalties) for PQRS non-participation in 2013, and negative 2 percent adjustments extending to 2016 and 2017 for non-PQRS participation in 2014 and 2015.

Who’s eligible? Physicians and certain other healthcare providers you might have in your practice, such as physician assistants, nurse practioners, and clinical nurse specialists qualify for PQRS. 

Check Out VBPM Facts

Originating in the Affordable Care Act (ACA), the value based payment modifier (VBPM) will “adjust payments to physicians, groups of physicians, and other EPs [eligible professionals] based on the quality and cost of care they furnish to beneficiaries enrolled in the traditional Medicare Fee-for-Service (FFS) program,” according to CMS. The 2015 Medicare Physician Fee Schedule final rule has since expedited the implementation of the VBPM.

CMS is already applying the VBPM in 2015 (based on 2013 reporting) for groups of 100 or more EPs. Now, solo practitioners and groups of two or more EPs are being phased in.

The plan is for providers to get payment incentives for high performance metrics and efficient spending — and payment penalties for underperformance or overspending. The VBPM quality composite score will be based on PQRS quality measures, “plus additional claims-based measures that CMS will calculate,” says Shari Erickson, VP of governmental affairs and public policy for the American College of Physicians.

CMS has a statutory mandate to implement the VBPM for all physicians by 2017. That means if you’re in a group of less than 100 physicians, your payments will first be affected in 2017 — but all payment adjustments will be based on your PQRS participation and performance in 2015. In other words, 2015 is a “reporting year” and 2017 is the respective “adjustment year” for solo practitioners and groups of fewer than 100.

Bottom line: You need to participate in PQRS this year. Based on 2015 non-participation in PQRS, groups of 10 or more EPs will receive a negative 4 percent VBPM penalty, and eligible solo practitioners and groups of 9 or fewer practitioners will see a negative 2 percent penalty in the adjustment year. 

Double-whammy: The PQRS nonparticipation penalty is still alive and well — and independent of the VBPM adjustment. By 2017, the PQRS penalty is negative 2 percent, and the VBPM penalty is either negative 2 or negative 4 percent, depending on your group size. That means in 2017, the total penalty for EPs could be as high as negative 6 percent. And if you count the meaningful use electronic health records (EHR) incentive program, some practitioners could see payment penalties as high as 11 percent.

Know How You’re Scored

So how are providers’ VBPM “scores” determined? Medicare is focusing on two major categories: quality and cost. In other words, is your care meeting basic standards, and are you providing it in a cost-effective manner? Quality and cost factors are determined by “quality tiering” — a comparison analysis by CMS of where you fall among your peers: Are you above average, average, or below average in your quality and cost factors? Depending on which one, your payment adjustment could go upward, downward, or be neutral.

At the moment, quality tiering analysis is optional. You can just choose a PQRS analysis, which saves you from a negative payment adjustment for 2015. However, for the 2016 VBPM, quality tiering is mandatory for groups with 10 or more EPs. Physicians in groups of 10 to 99 EPs will be subject to an upward or neutral payment adjustment, while groups of physicians with 100 or more EPs will be subject to an upward, neutral, or downward payment adjustment.

Option: If you’re in a group of two or more EPs, you can elect to have your patient experience measures from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) PQRS survey included in your quality of care composite.

A key to VBPM scoring will be based on Quality Resource and Use Reports (QRURs), also known as Physician Feedback Reports. CMS distributed these reports in late 2014, which represented 2013 data on comparative performance.

These QRURs contain performance information on the quality and cost measures used to calculate the quality and cost composites of the VBPM for CY 2015 payment adjustments. “There are two different types of reports you can access — one is the NPI identifier level report, the other is a PIN-level report,” explained CMS’s Christina Phillips during an Open Door Forum informational call on the topic.

How You Can Prepare

If your head is swimming with facts and numbers at this point, take a pause. Determine the size of your group, which will determine your reporting year, and go from there. 

“We advise group practices to familiarize themselves with how they will be impacted by the modifier, participate in PQRS to avoid an automatic double penalty, and to learn more about the outcomes and cost measures by downloading their quality resource and use reports (QRUR),” says Allison Brennan, senior advocacy advisor for Medical Group Management Association (MGMA). 

Concern: The complexity of these “quality” programs continues to frustrate some in the industry. 

“Medicare has lost focus with its physician quality reporting programs,” said Anders Gilberg, MGMA senior VP of government affairs in a press release. “Instead of providing timely, meaningful, and actionable information to help physicians treat patients, this has become a massive bureaucratic reporting exercise …. which forces physician practices to divert resources away from patient care.”