Pain Management Coding Alert

Published on Thu Jun 08, 2017 PDF

As PQRS exits the stage, MIPS makes its debut.

Despite assumptions to the contrary, the end of the Physician Quality Reporting System (PQRS) does not mean that Medicare payers have abandoned quality reporting measures.

The skinny: Quality reporting is getting even bigger under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which “represents the most significant change to Medicare’s physician payment system in a generation …” according to Andrew Gurman, MD, AMA president, in a press release responding to the final rule.

Don’t sleep on MACRA if you want to preserve your Medicare pay this year and moving into the future. Don’t let your practice reflect a recent survey performed by The Physicians Foundation that “found that only 20 percent of physicians are familiar with MACRA,” according to Sarah Warden, Esq., of Greenspoon Marder in Ft. Lauderdale, Florida.

Check it out:  Study the following FAQs to be sure that you are in line to maximize your reimbursement — or at least avoid pitfalls that will result in a negative payment adjustment for your providers.

Q: What is MACRA?

A: It is a quality reporting program, similar to earlier programs such as Physician Quality Reporting System (PQRS), the Electronic Health Record (EHR) incentive program called “Meaningful Use,” and Value-Based Payment Modifier (VM). Before MACRA, Medicare paid physicians based on a fee-for-service structure called the Sustainable Growth Rate (SGR). However, CMS had instituted several quality reporting initiatives in recent years, such as PQRS, Meaningful Use, and VM.

All of these programs started out as voluntary, and varied in payment impact from neutral, to small incentives, to penalties. In fact, eligible clinicians who didn’t report PQRS measures for 2016 services can expect a 2 percent payment reduction from Medicare Physician Fee Schedule rates in 2018, according to Carol Jones, MSN, CMS Program Analyst, in an MLN Connects National Provider Call earlier this year.

Under MACRA, CMS phases out data collection for any of the previous programs for services beginning Jan. 1, 2017 (although data reporting from performance-year 2016 continues into 2017). Instead, you’ll have a new Quality Payment Program (QPP) with two paths: Advanced Alternative Payment Model (APMs) (which most practices won’t qualify for this year), or Merit-Based Incentive Payment System (MIPS).

Important: Eligible clinicians must report data using MIPS in 2017 or face payment penalties in 2019.

MIPS aims to evaluate performance under four categories, three of which parallel the three terminated programs, as follows:

• Quality — primarily replaces PQRS
• Advancing Care Information — primarily replaces Meaningful Use of EHR
• Cost — primarily replaces VM
• Improvement Activities — new quality category for evaluation.

Clinicians will receive a score in each category, which CMS weights according to the relative importance assigned to each, to arrive at a single score between 0 and 100. The category weight may change over time and based on clinician characteristics.

Q: Do We Have to Fully Participate in MIPS?

A: No, MIPS is not all or nothing in terms of payment or penalty — especially in 2017 when CMS actually makes it easy to avoid the penalty. The MIPS program comes with a “pick your pace” option that allows you to start your reporting as small or as big as you’re ready to go. Here are the participation categories and the rewards or penalties for each:

• Non-participation: If your physician is eligible for MIPS and does nothing in 2017, you can expect a negative 4 percent adjustment to payment in 2019.
• Test: If you just try out MIPS — say one quality measure for one patient, or one improvement activity — you’ll avoid the 4 percent penalty.
• Partial year: For submitting data for 90 days in 2017, you may earn a small positive payment adjustment.
• Full year: You can earn a moderate payment increase for a full year of reporting data.