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Medicare Billing Boosters April 2015

Novitas Solutions to Hold Symposium in Biloxi in May

Novitas recently announced the Medicare educational symposiums to be held in 2015. Sites include Albuquerque, Biloxi, Denver, Little Rock and Frisco, TX. For more information and to register for the free event see

Meaningful Use- Modified Stage 2 (and 1)

In April, CMS issued another proposal for “meaningful use” with the goal of aligning Stage 1 and Stage 2 objectives with the long-term proposals for Stage 3. The change from the original Stage 2 requirements are to reduce reporting requirements which would allow providers to focus on advanced use of EHR technology and quality improvements and better promote interoperability. The plan would not be issued as a final regulation until August of this year; however, it applies to MU for years 2015, 2016 and 2017. So in August of 2015, providers will receive the final rule affecting 2015.

The proposal reduces the number of MU objectives to focus on the advanced use of EHRs; removes measures that have become redundant or have reached wide-spread adoption; realigns the reporting period to a calendar year instead of fiscal year; and allows for a 90 day reporting period in 2015.

Modified objectives of particular interest are the patient electronic access and patient electronic messaging. The original MU measure was 5% while the modified MU is 1 patient for electronic access and a “functionality fully enabled” for electronic messaging.

If a provider is currently attempting Stage 1 MU, it also was modified for Stage 2 criteria, but with smaller less comprehensive measures.

Meaningful Use Stage 3 Released

The proposed rule for stage 3 of “meaningful use” EHR Incentive Program was also recently released. It contains 8 objectives focused on advanced use of EHRs. The rule proposed significant change to the structure of the program by establishing a single stage for MU (Stage 3) starting in 2018. This would require eligible professionals to comply with MU requirements by 2018, regardless of their prior participation in the program. It is predicted that the cost to purchase and implement a certified EHR would be $54,000 and $10,000 annually for maintenance. The patient engagement requirement jumps from 5% in the original stage 2 to 25% of patients in stage 3. Starting in 2018, CMS would require electronic quality reporting for providers who would need to implement 5 clinical decision support interventions related to four or more quality measures. CMS insists that stage 3 includes some flexibility to help providers successfully attest. By 2019, MU will be rolled into a consolidated program under Merit-Based Incentives.

Burdensome Meaningful Use Audits Snag Family Physicians

AAFP recently issued a letter to CMS pointing out concerns regarding MU audits. You can read about it in this AAFP article.

PQRS, VBM, MU EHR and now MIPS- Alphabet Soup That Isn’t That Tasty! Act Now to Avoid Penalties!

By now, everyone should be aware that fee-for-service payment is on its way out and a value-based payment system is on its way. But all the program abbreviations being tossed around can be confusing!

Provider’s wallets are probably already familiar with this one: The Tax Relief and Health Care Act of 2006 included the current day Physician Quality Reporting System (PQRS) program. If providers do not participate in PQRS adjustments (aka penalties) will be assessed. Acceptable reporting options include claims submission, EHRs and Data Reporting Registries. For more information see this CMS Presentation.


2013 +0.5% in 2015 -1.5% in 2015

2014 +0.5% in 2016 -2.0% in 2016

2015 --- -2.0% in 2017

2016 --- -2.0% in 2018

But wait! There’s More!” The Affordable Care Act required Medicare to establish a Value-Based Modifier (VBM) payment system that provides the differential payment to providers based on the quality of care furnished to beneficiaries compared to the cost of that care during a performance period. It does not replace the PQRS Program- it builds on it. It applies only to provider payments under the Medicare physician fee schedule. In 2015, the VBM will affect Medicare payments to physicians in groups of 100 or more eligible professionals (basically ALL healthcare professionals) based on 2013 performance on quality and cost measures. In 2016, the modifier will apply to physicians in groups of 10 or more based on 2014 performance. In 2017, the modifier will apply to ALL physicians -regardless of group size-based on 2015 performance. The modifier is not a CPT modifier like one would expect, but is tied to the provider’s Tax ID number. Individual patients are “attributed” to a provider’s practice. The modifier is based on PQRS and is composed of quality and cost “tiering” measures comparing to the mean of the physician’s peer group. To participate for 2015 and thus avoid a 2017 penalty, providers should download their individual Quality and Resource Use Report immediately using your log-on credentials. In addition, read the CMS document regarding VBM here.

Fast forward to 2019: As if the waters weren’t already muddied enough, on April 16th, President Obama signed into law the Medicare and CHIP Reauthorization Act (MACRA), which replaces the Sustainable Growth Rate (SGR) Formula which was a good thing. But, it also significantly changes the payment models for 2019. The bill rolls the PQRS, Value-Based Modifier and EHR Meaningful Use into one consolidated program: Merit-Based Incentive Payment System (MIPS). HHS will establish a list of MIPS quality measures through rulemaking. Professionals will receive a composite performance score based on assessment from four performance categories:

  • Quality (Using measures from existing quality programs and new ones developed by professional organizations);

  • Resource use, using measures developed by the current VBM program;

  • EHR ‘meaningful use’ (using requirements established under current regulation); and,

  • “Clinical practice improvement activities”, which “gives credit to professionals working to improve their practices and facilities future participation in APMs” (Application Performance Management).

If you plan to be in practice in 5 years, the change is inevitable. Since value- based reporting is most definitely here to stay, it is highly recommended that providers participate in PQRS and VBM for 2015 to stop the penalties in 2016/2017!

You might want to sit down for this: With the 2 % sequestration “adjustment”, if a provider (in a practice with 9 or fewer providers) does not participate at all in PQRS, MU EHR, or VBM in 2015, by 2017 the cost will be 9% of the fee schedule. In 2018, it could be as high as 11%! Ouch!

CMS Clarifies Chronic Care Management Codes in Advantage Plans

In January, Medicare began paying providers for Chronic Care Management Services; however, there was confusion on whether these codes could be used for a patient with a Medicare Advantage Plan. In April, CMS confirmed in a conference call with physician groups and released a memo stating that Chronic Care Management services were covered by Medicare Part B which included Medicare Advantage plans. However, Advantage Plans have wide latitude in terms of furnishing care coordination services to beneficiaries. Regulation expressly precludes CMS from interfering in payment rates agreed to by plans and providers. Therefore, coverage can vary depending on the contract in place.

Additional information regarding the patient’s ability to go outside their plan network to obtain Chronic Care services was also addressed. If a patient chooses an out-of-network provider for these services and the criteria for billing the Chronic Care code is satisfied, then the Advantage Plan must pay for services as an out-of-network physician service where patients would be responsible for cost-sharing.

The patient receiving the services must authorize the provider to provide the services and only one provider may bill for them in a single month for a single patient.

Lung Cancer Screening and Counseling Added to Preventive Services

The national coverage determination issued in February now adds lung cancer screening, counseling and shared decision-making services as an additional preventive benefit. Cancer screening will include low-dose computed tomography (LDCT) once annually for patients who meet certain eligibility requirements:

  • Be between ages 55 and 57

  • Be asymptomatic of lung cancer

  • Be a current smoker or former smoker who stopped in past 15 years

  • Have a smoking history of an average of one pack a day for 30 years

  • Have a written order from provider (counseling provided by physician or qualified NPP)

  • Screening must be done at an eligible facility.

Read the CMS Press Release here.

Novitas Issues Guidance on the New Modifiers for -59

The new X Modifiers to be used in place of Modifier -59 have been in place since January of 2015; however, CMS didn’t issue much information on practically how they were to be used. Novitas Solutions issued this guidance in February which included examples but we are hearing stories of how the new modifiers won't pay. Hopefully additional help will come.

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