Meet the Presenter. Welcome to PMI s Webinar Presentation. On the topic: Brought to you by: Practice Management Institute pmimd.

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1 Welcome to PMI s Webinar Presentation Brought to you by: pmimd.com Meet the Presenter Pam Joslin, MM, CMC, CMIS, CMOM, CMCO, CEMA On the topic: Coding & Medicare Changes for 2018

2 Welcome to s Webinar and Audio Conference Training. We hope that the information contained herein will give you valuable tips that you can use to improve your skills and performance on the job. Each year, more than 40,000 physicians and office staff are trained by. For 30 years, physicians have relied on PMI to provide up-to-date coding, reimbursement, compliance and office management training. Instructor-led classes are presented in 400 of the nation s leading hospitals, healthcare systems, colleges and medical societies. PMI provides a number of other training resources for your practice, including national conferences for medical office professionals, self-paced certification preparatory courses, online training, educational audio downloads, and practice reference materials. For more information, visit PMI s web site at Please be advised that all information in this program is provided for informational purposes only. While PMI makes all reasonable efforts to verify the credentials of instructors and the information provided, it is not intended to serve as legal advice. The opinions expressed are those of the individual presenter and do not necessarily reflect the viewpoint of Practice Management Institute. The information provided is general in nature. Depending on the particular facts at issue, it may or may not apply to your situation. Participants requiring specific guidance should contact their legal counsel. CPT is a registered trademark of the American Medical Association Vicar San Antonio, Texas tel: fax: (210) info@pmimd.com

3 Coding and Medicare Changes for 2018 Brought to you by: Pam Joslin, MM, CMC, CMIS, CMOM, CMCO, CEMA Current Procedural Terminology (CPT ) is copyright 2016 of the American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use

4 MEDICARE PHYSICIAN FEE SCHEDULE FINAL RULE Final Policy, Payment, and Quality Provisions in the Medicare Physician Fee Schedule for Calendar Year 2018 On November 2, 2017, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that includes updates to payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, The calendar year (CY) 2018 PFS final rule is one of several final rules that reflect a broader Administration-wide strategy to create a healthcare system that results in better accessibility, quality, affordability, empowerment, and innovation

5 Background on the Physician Fee Schedule Since January 1, 1992, Medicare has paid for physicians services under section 1848 of the Act, Payment for Physicians Services. The PFS relies on national relative values that are established for work, PE, and MP, which are adjusted for geographic cost variations. These values are multiplied by a conversion factor (CF) to convert the Relative Value Units (RVUs) into payment rates Background on the Physician Fee Schedule Payment is made under the PFS for services furnished by physicians and other practitioners in all sites of service. These services include, but are not limited to, visits, surgical procedures, diagnostic tests, therapy services, and specified preventive services. In addition to physicians, payment is made under the PFS to a variety of practitioners and entities, including nurse practitioners, physician assistants, and physical therapists, as well as radiation therapy centers and independent diagnostic testing facilities. Payments are based on the relative resources typically used to furnish the service. Relative Value Units (RVUs) are applied to each service for physician work, practice expense, and malpractice. These RVUs become payment rates through the application of a conversion factor. Payment rates are calculated to include an overall payment update specified by statute

6 Summary This major final rule addresses changes to the Medicare physician fee schedule (PFS) and other Medicare Part B payment policies such as changes to the Medicare Shared Savings Program, to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services, as well as changes in the statute. In addition, this final rule includes policies necessary to begin offering the expanded Medicare Diabetes Prevention Program model Patients Over Paperwork CMS recently launched the Patients Over Paperwork Initiative, a cross-cutting, collaborative process that evaluates and streamlines regulations with a goal to reduce unnecessary burden, increase efficiencies, and improve the beneficiary experience. This effort emphasizes a commitment to removing regulatory obstacles that get in the way of providers spending time with patients. The Medicare Physician Fee Schedule final rule includes the following as part of this initiative: reducing reporting requirements and removing downward payment adjustments based on performance for practices that meet minimum quality reporting requirements

7 Summary of Major Payment Provisions Changes in Valuation for Specific Services: CMS reviews the resource inputs for several hundred codes under the annual process referred to as the potentially misvalued code initiative. Recommendations from the American Medical Association-Relative Value Scale Update Committee (RUC) are critically important to this work. For CY 2018, CMS is finalizing the values for individual services that generally reflect the expert recommendations from the RUC without as many refinements as CMS made in recent years Medicare Parts A & B Part A hospital inpatient deductible and coinsurance In 2018 you will pay: $1, Medicare deductible for each benefit period Days 1-60: $0 coinsurance for each benefit period Days 61-90: $329 coinsurance per day of each benefit period Days 91 and beyond: $658 coinsurance per each lifetime reserve day after day 90 for each benefit period (up to 60 days over your lifetime) Beyond lifetime reserve days: all costs

8 Medicare Parts A & B Medicare Part B deductible and coinsurance is $183 per year. After your 2018 Medicare deductible is met, you typically pay 20% of the Medicare-approved amount for most doctor services (including most doctor services while you re a hospital inpatient), outpatient therapy, and durable medical equipment. The Part C monthly premium varies by plan. Compare costs for specific Part C plans. Part D premium monthly premium varies by plan (higher-income consumers may pay more). Compare costs for specific Part D plans Medicare 2018 Part A & B Premiums Medicare 2018 Part A Premium Many, if not most people won t have to pay a monthly premium for Part A Medicare in If you have to buy Part A you will pay up to $413 each month. Medicare 2018 Part B Premium The standard Part B premium amount is $134 (or higher depending on your income). However, most people who get Social Security benefits will pay less than this amount ($109 on average)

9 Preventive Codes Billed with Prolonged Service Code HCPCS Short Desc Typical Time with Patient (assumed for valuation) Clinical Staff Biller Us abdl aorta screen aaa Us bone density measure screening mammography Breast tomosynthesis bi Ct bone density axial Dxa bone density axial Dxa bone density/peripheral 22 G0101 Ca screen; pelvic/breast exam 10 G0104 Ca screen; flexi sigmoidscope 17 G0105 Colorectal scrn; hi risk ind 30 G0121 Colon ca scrn not hi risk ind 30 G0130 Single energy x-ray study 26 G0202 Scr mammo bi incl cad 23 G0296 Visit to determ ldct elig 15 G0297 Ldct for lung ca screen 32 G0402 Initial preventive exam 30 G0438 Ppps, initial visit 30 G0439 Ppps, subseq visit 25 Q0091 Obtaining screen pap smear Diagnostic Cardiovascular Services Subject to the Multiple Procedure Payment Reduction CY 2018 Code Short Descriptor Contrast x-ray exam of aorta Contrast x-ray exam of aorta Contrast x-ray exam of aorta X-ray aorta leg arteries Artery x-rays arm Artery x-rays spine Artery x-rays arm/leg Artery x-rays arms/legs Artery x-rays abdomen Artery x-rays adrenal gland Artery x-rays adrenals Artery x-rays pelvis

10 Diagnostic Cardiovascular Services Subject to the Multiple Procedure Payment Reduction CY 2018 Code Short Descriptor Artery x-rays lungs Artery x-rays lungs Artery x-rays lungs Artery x-rays chest Av dialysis shunt imaging Nonvascular shunt x-ray Vein x-ray arm/leg Vein x-ray arms/legs Vein x-ray trunk Vein x-ray chest Vein x-ray kidney Vein x-ray kidneys Vein x-ray adrenal gland Vein x-ray adrenal glands Malpractice Relative Value Units (RVUs) For CY 2017, we collected updated professional liability insurance data for the purposes of updating the malpractice geographic practice cost indices, but we did not propose to use the data to update the specialty risk factors used in the calculation of malpractice RVUs at that time. Rather, we solicited comment on whether we should consider updating the malpractice RVUs based on the updated professional liability insurance data prior to the next expected 5-year update (CY 2020)

11 Determination of Malpractice RVUs The MP RVUs are based on commercial and physician-owned insurers malpractice insurance premium data from all the states, the District of Columbia, and Puerto Rico. To determine MP RVUs for individual PFS services, our MP methodology is composed of three factors: 1) specialty level risk factors derived from data on specialty-specific MP premiums incurred by practitioners, 2) service level risk factors derived from Medicare claims data of the weighted average risk factors of the specialties that furnish each service, and 3) an intensity/complexity of service adjustment to the service level risk factor based on either the higher of the work RVU or clinical labor RVU Steps for Calculating Malpractice RVUs Step 1: Compute a preliminary national average premium for each specialty. Step 2: Determine which premium class(es) to use within each specialty. Step 3: Calculate a risk factor for each specialty

12 CY 2018 Malpractice Risk Factors and Premium Amounts by Specialty (excerpt) Steps for Calculating Malpractice RVUs Step 4: Calculate malpractice RVUs for each HCPCS code. Step 5: Rescale for budget neutrality

13 Work RVUs The work component of physicians services means the portion of the resources used in furnishing the service that reflects physician time and intensity. We establish work RVUs for new, revised and potentially misvalued codes Determination of Practice Expense RVUs We were required to consider general categories of expenses (such as office rent and wages of personnel, but excluding malpractice expenses) comprising PEs. The PE RVUs continue to represent the portion of these resources involved in furnishing PFS services. Separate PE RVUs are established for services furnished in facility settings, such as a hospital outpatient department (HOPD) or an ambulatory surgical center (ASC), and in nonfacility settings, such as a physician s office. The nonfacility RVUs reflect all of the direct and indirect PEs involved in furnishing a service described by a particular HCPCS code

14 Calculation of Payments Based on RVUs Payment = [(RVU work x GPCI work) + (RVU PE x GPCI PE) + (RVU MP x GPCI MP)] x CF Medicare Telehealth Services For CY 2018, CMS is finalizing the addition of several codes to the list of telehealth services, including: HCPCS code G0296 (visit to determine low dose computed tomography (LDCT) eligibility); CPT code (Interactive Complexity); CPT codes and (Health Risk Assessment); HCPCS code G0506 (Care Planning for Chronic Care Management); and CPT codes and (Psychotherapy for Crisis). Additionally, we are finalizing our proposal to eliminate the required reporting of the telehealth modifier GT for professional claims in an effort to reduce administrative burden for practitioners

15 Medicare Telehealth Services We are also finalizing separate payment for CPT code 99091, which describes certain remote patient monitoring, for CY In the final rule, we are finalizing separate payment for CPT code 99091: (Collection and interpretation of physiologic data (e.g., ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional, qualified by education, training, licensure/regulation (when applicable) requiring a minimum of 30 minutes of time, for 2018 pending anticipated changes in CPT coding Medicare Telehealth Services As specified at (b), we generally require that a telehealth service be furnished via an interactive telecommunications system. An interactive telecommunications system is: defined as multimedia communications equipment that includes, at a minimum, audio and video equipment permitting two-way, real-time interactive communication between the patient and distant site physician or practitioner

16 Medicare Telehealth Services Telephones, facsimile machines, and stand-alone electronic mail systems do not meet the definition of an interactive telecommunications system. An interactive telecommunications system is generally required as a condition of payment; however, section 1834(m)(1) of the Act allows the use of asynchronous store-and-forward technology when the originating site is part of a federal telemedicine demonstration program in Alaska or Hawaii Medicare Telehealth Services Medicare telehealth services may be furnished to an eligible telehealth individual notwithstanding the fact that the practitioner furnishing the telehealth service is not at the same location as the beneficiary. An eligible telehealth individual is an individual enrolled under Part B who receives a telehealth service furnished at a telehealth originating site

17 Medicare Telehealth Services Effective January 1, 2014, we modified the regulations regarding originating sites to define rural Health Professional Shortage Areas (HPSAs) as those located in rural census tracts as determined by the Federal Office of Rural Health Policy of the Health Resources and Services Administration (HRSA) (78 FR 74811). Defining rural to include geographic areas located in rural census tracts within Metropolitan Statistical Areas (MSAs) allows for broader inclusion of sites within HPSAs as telehealth originating sites Medicare Telehealth Services Adopting the more precise definition of rural for this purpose expands access to health care services for Medicare beneficiaries located in rural areas. HRSA has developed a Web site tool to provide assistance to potential originating sites to determine their geographic status. To access this tool, see our Web site at Information/Telehealth/index.html

18 Submitted Requests to Add Services to the List of Telehealth Services for CY 2018 We proposed to add the following services to the telehealth list on a category 1 basis for CY 2018: HCPCS code G0296 (Counseling visit to discuss need for lung cancer screening using low dose ct scan (ldct) (service is for eligibility determination and shared decision making)) CPT codes and (Psychotherapy for crisis; first 60 minutes) and (Psychotherapy for crisis; each additional 30 minutes (List separately in addition to code for primary service)) List of Telehealth Services for CY 2018 Although we did not receive specific requests, we also proposed to add four additional services to the telehealth list based on our review of services. CPT code (Interactive complexity (List separately in addition to the code for primary procedure)) CPT codes and (Administration of patient-focused health risk assessment instrument (eg, health hazard appraisal) with scoring and documentation, per standardized instrument) and (Administration of caregiver-focused health risk assessment instrument (eg, depression inventory) for the benefit of the patient, with scoring and documentation, per standardized instrument))

19 List of Telehealth Services for CY 2018 HCPCS code G0506 (Comprehensive assessment of and care planning for patients requiring chronic care management services (list separately in addition to primary monthly care management service)) In the case of CPT codes and 96161, and HCPCS code G0506, we recognized that these services may not necessarily be ordinarily furnished in-person with a physician or billing practitioner. We believed that by adding these services to the telehealth list it will be administratively easier for practitioners who report these services in association with a visit code that is furnished via telehealth as both the base code and the add-on code would be reported with the telehealth place of service Elimination of the Required Use of the GT Modifier on Professional Claims Medicare has required distant site practitioners to report one of two longstanding HCPCS modifiers when reporting telehealth services. Current guidance instructs practitioners to submit claims for telehealth services using the appropriate CPT or HCPCS code for the professional service along with the telehealth modifier GT (via interactive audio and video telecommunications systems)

20 Elimination of the Required Use of the GT Modifier on Professional Claims For federal telemedicine demonstration programs in Alaska or Hawaii, practitioners are instructed to submit claims using the appropriate CPT or HCPCS code for the professional service along with the telehealth modifier GQ if telehealth services are performed via an asynchronous telecommunications system. By coding and billing these modifiers with a service code, practitioners are certifying that both the broad and code-specific telehealth requirements have been met Improvement of Payment Rates for Office-based Behavioral Health Services CMS is finalizing an improvement in the way physician fee schedule rates are set that will positively impact office-based behavioral health services with a patient. The final policy will increase payment for these important services by better recognizing overhead expenses for officebased face-to-face services with a patient

21 New Care Coordination Services and Payment for Rural Health Clinics (RHCs) and Federally- Qualified Health Centers (FQHCs) CMS is finalizing the proposal to revise payment for chronic care management in RHCs and FQHCs, and establish requirements and payment for RHCs and FQHCs furnishing general behavioral health integration (BHI) services and psychiatric collaborative care model (CoCM) services. Effective January 1, 2018, RHCs and FQHCs will be paid for chronic care management (CCM), general BHI, and psychiatric CoCM using two new billing codes created exclusively for RHC and FQHC payment. This payment would be in addition to the payment for an RHC or FQHC visit Medicare Diabetes Prevention Program Expanded Model The final rule also implements the Medicare Diabetes Prevention Program (MDPP) expanded model starting in The final rule includes additional policies necessary for suppliers to begin furnishing MDPP services nationally in 2018, including the MDPP payment structure, as well as additional supplier enrollment requirements and supplier compliance standards aimed to enhance program integrity

22 Payment Modifiers Payment modifiers are accounted for in the creation of the file consistent with current payment policy as implemented in claims processing. For example, services billed with the assistant at surgery modifier are paid 16 percent of the PFS amount for that service; therefore, the utilization file is modified to only account for 16 percent of any service that contains the assistant at surgery modifier Application of Payment Modifiers to Utilization Files

23 Changes to Direct PE Inputs for Specific Services The direct PE inputs are included in the CY 2018 direct PE input database, which is available on the CMS website under downloads for the CY 2018 PFS final rule: Service-Payment/PhysicianFeeSched/PFS-Federal- Regulation-Notices.html Changes to Direct PE Inputs for Specific Services For CY 2018, we proposed to make direct PE changes for CPT code 96416: (Chemotherapy administration, intravenous infusion technique; initiation of prolonged chemotherapy infusion (more than 8 hours), requiring use of a portable or implantable pump) to improve payment accuracy, in response to a stakeholder inquiry regarding the use of the ambulatory IV pump equipment for this service

24 Changes to Direct PE Inputs for Specific Services We proposed to add 6 additional minutes of RN/OCN (Registered Nurse/Oncology Certified Nurse) clinical labor (L056A), 4 minutes for the Review charts by chemo nurse regarding course of treatment & obtain chemotherapy-related medical hx task, and 2 minutes for the Greet patient and provide gowning task Changes to Direct PE Inputs for Specific Services We proposed to correct an anomaly in the postservice work time for CPT code (Liver elastography, mechanically induced shear wave (eg, vibration), without imaging, with interpretation and report) by changing it from 5 minutes to 3 minutes, which also results in a refinement in the total work time for the code from 18 minutes to 16 minutes

25 Direct PE Database Data Discrepancies and Proposed Changes (excerpt) Changes to Direct PE Inputs for Specific Services After consideration of comments received, we are finalizing the direct PE changes to CPT code as proposed, the correction to an anomaly in the postservice work time for CPT code as proposed, and the proposed changes to the direct PE database

26 Overall Payment Update and Misvalued Code Target The overall update to payments under the PFS based on the finalized CY 2018 rates will be percent. This update reflects the percent update established under the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, reduced by 0.09 percent, due to the misvalued code target recapture amount, required under the Achieving a Better Life Experience (ABLE) Act of After applying these adjustments, and the budget neutrality adjustment to account for changes in RVUs, all required by law, the final 2018 PFS conversion factor is $35.99, an increase to the 2017 PFS conversion factor of $ CY 2018 Identification and Review of Potentially Misvalued Services CPT code (Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device) was nominated for review as a potentially misvalued code because the current work RVU is potentially undervalued and stakeholders recommend that it should be increased to After reviewing the range of public comments, we agree with commenters that CPT code is a potentially misvalued, and believe that a comprehensive review of the code values is warranted

27 CY 2018 Identification and Review of Potentially Misvalued Services Dialysis vascular access codes newly created in CY 2017 (CPT codes through 36909) did not include data that would warrant increases to the work RVUs. For CY 2018, we are finalizing the CY 2017 RUC-recommended (RUC = RVS Update Committee) work RVUs for CPT codes , consistent with the requests of public commenters CY 2018 Identification and Review of Potentially Misvalued Services We sought additional comment and requested robust data regarding the potentially misvalued work RVUs for CPT codes through and considered alternate work valuations for CY 2018, such as the RUC-recommended work RVUs from CY 2017, or other potential values based on submission of data through the public comment process. For CY 2018, we are finalizing the CY 2017 RUCrecommended work RVUs for CPT codes

28 CY 2018 Identification and Review of Potentially Misvalued Services We have received conflicting information about the direct PE inputs for CPT codes (Flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; first marker) and (Flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; each additional marker (List separately in addition to code for first marker)). In the CY 2018 PFS proposed rule, we proposed these codes as potentially misvalued so that they can be reviewed again because some stakeholders have suggested the clinical labor and supplies that were previously finalized are no longer accurate CY 2018 Identification and Review of Potentially Misvalued Services We are finalizing a clinical labor time of 15 minutes for the Instrument start-up, quality control functions clinical labor activity for CPT code We are finalizing a clinical labor time of 10 minutes for the Load specimen into flow cytometer clinical labor activity for CPT code We are finalizing a supply quantity of 1.6 for the flow cytometry antibody in these two CPT codes

29 Emergency Department Visits Comment Solicitation Comment Solicitation on Emergency Department Payment Rates (CPT codes ) We received information suggesting that the work RVUs for emergency department visits did not appropriately reflect the full resources involved in furnishing these services. Therefore, we sought comment on whether CPT codes (Emergency department visits for the evaluation and management of a patient) should be reviewed under the misvalued code initiative Emergency Department Visits Comment Solicitation We agree with the majority of commenters that these services may be potentially misvalued given the increased acuity of the patient population and the heterogeneity of the sites where emergency department visits are furnished. As a result, we look forward to reviewing the RUC s recommendations regarding the appropriate valuation of these services for our consideration in future notice and comment rulemaking

30 CMS has Prioritized the Following Screens: Codes with low work RVUs commonly billed in multiple units per single encounter. Codes with high volume and low work RVUs. Codes with site-of-service anomalies. E/M codes. PFS high expenditure services. Services with standalone PE procedure time. Services with anomalous time CMS has Prioritized the Following Screens: Contractor Medical Director identified potentially misvalued codes. Codes with higher total Medicare payments in office than in hospital or ASC. Publicly nominated potentially misvalued codes. 0-day global services that are typically billed with an evaluation and management (E/M) service with modifier

31 Comment Solicitation on New Potentially Misvalued Code Screens Although we did not propose a new screen for CY 2018, we continue to believe that it is important to prioritize codes for review under the misvalued code initiative. As a result, we solicited public comment on the best approach for developing screens, as well as what particular new screens we might consider CY 2018 Work RVUs for New, Revised and Potentially Misvalued Codes(excerpt)

32 E/M Guidelines and Care Management Services CPT Editorial Panel (CPT) to develop and value (or revalue) the following service codes: Transitional care management (TCM) services (2013). Chronic care management services (CCM) (2015, 2017). Behavioral health integration (BHI) services (2017). Assessment/care planning services for cognitive impairment (2017). Prolonged E/M services without direct patient contact (2017) E/M Guidelines Public Comment Solicitation We specifically sought comment on how we might focus on initial changes to the guidelines for the history and physical exam, because we believe documentation for these elements may be more significantly outdated, and that differences in Medical Decision Making (MDM) are likely the most important factors in distinctions between visits of different levels. We also specifically sought comment on whether it would be appropriate to remove our documentation requirements for the history and physical exam for all E/M visits at all levels. We stated that we believed MDM and time are the more significant factors in distinguishing visit levels, and that the need for extended histories and exams is being replaced by population-based screening and intervention, at least for some specialties

33 E/M Guidelines Public Comment Solicitation As long as a history and physical exam are documented and generally consistent with complexity of MDM, we believed there may no longer be a need for us to maintain such detailed specifications for what must be performed and documented for the history and physical exam (for example, which and how many body systems are involved). We sought comment on whether clinicians and other stakeholders believe removing the documentation requirements for the history and physical exam would be a good approach. Although we believed that MDM guidelines may also need to be updated, we stated our belief that in the near term, it may be possible to eliminate the current focus on details of history and physical exam, and allow MDM and/or time to serve as the key determinant of E/M visit level E/M Guidelines Public Comment Solicitation There was no consensus among commenters on changes that would need to be made to MDM and time rules in order for CMS to rely more on these elements (in lieu of history and exam) to justify service level billed. Commenters frequently suggested that we provide additional avenues for collaboration with stakeholders prior to implementing any changes. We are currently considering the best approaches for such collaboration, and will take the comments into account as we consider the issues for future rulemaking. We expect to continue to work on all of these issues with stakeholders in future years though we are immediately focused on revision of the current E/M guidelines in order to reduce unnecessary administrative burden

34 Key Component Documentation Requirements for Level 2 vs Level 3 E/M New Care Coordination Services and Payment for RHCs and FQHCs RHC: Rural health Clinics FQHC: Federally Qualified Health Centers We finalized the establishment of two new G codes for use by RHCs and FQHCs. The first new G code is a General Care Management code for RHCs and FQHCs with the payment amount set at the average of the 3 national nonfacility PFS payment rates for the CCM and general BHI codes. The second new G code for RHCs and FQHCs is a Psychiatric CoCM code with the payment amount set at the average of the 2 national non-facility PFS payment rates for psychiatric CoCM services. The payment rate for each code will be updated annually, based on the national non-facility PFS payment rates for each code contained in the G code

35 New Care Coordination Services and Payment for RHCs and FQHCs Establishment of the RHC and FQHC General Care Management code, which includes all levels of CCM and general BHI services, is projected to increase Medicare spending by $2.2 million in CY 2018 and by $25.5 million over 10 years. Establishment of the RHC and FQHC Psychiatric CoCM code, which includes all levels of psychiatric CoCM services, is projected to increase Medicare spending by approximately $100,000 in CY 2018 and $4.0 million over 10 years. Although these services are expected to increase quality and improve efficiency over time, the programs are still new and the data is not available yet to demonstrate any cost savings Calendar Years Projected Spending Impact of New General Care Management and Psychiatric CoCM Codes for RHCs and FQHCs (Millions)

36 New Care Coordination Services and Payment for RHCs and FQHCs Effective for services furnished on or after January 1, 2018, we are proposing to create General Care Management code GCCC1 for RHCs and FQHCs, with the payment amount set at the average of the 3 national non-facility PFS payment rates for the CCM and general behavioral health integration (BHI) codes and updated annually based on the PFS amounts New Care Coordination Services and Payment for RHCs and FQHCs The 3 codes are: CPT minutes or more of Chronic care management (CCM) services CPT at least 60 minutes of complex CCM services HCPCS G minutes or more of behavioral health integration (BHI) services

37 Comparison of Proposed CCM and General BHI Requirements and Payment For RHCs and FQHCs (excerpt) Payment for Care Management Codes under the PFS CCM Services (CPT Code and CPT Code 99489) CPT code is for complex CCM services. It requires multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; chronic conditions that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; establishment or substantial revision of a comprehensive care plan; moderate or high complexity medical decision making; and 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month

38 CCM Services (CPT Code and CPT Code 99489) CPT code is for each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month. Practitioners paid under the PFS can bill either complex (CPT code and CPT code 99489) or non-complex (CPT code 99490) CCM services during a given service period, and can submit only one professional claim for CCM services for that service period Physician Quality Reporting System (PQRS) Under the PQRS, individual eligible professionals and group practices who did not satisfactorily report data on quality measures for the CY 2016 reporting period are subject to a downward payment adjustment of 2.0 percent in 2018 to their PFS covered professional services was the last reporting period for PQRS. The final data submission timeframe for reporting 2016 PQRS quality data to avoid the 2018 PQRS downward payment adjustment was January through March

39 Physician Quality Reporting System (PQRS) PQRS is being replaced by the Merit-based Incentive Payment System (MIPS) under the Quality Payment Program (QPP). The first MIPS performance period is January through December CMS proposed and is finalizing a change to the current PQRS program policy that requires reporting of 9 measures across 3 National Quality Strategy domains to only require reporting of 6 measures for the PQRS with no domain requirement Physician Quality Reporting System (PQRS) We are also finalizing similar changes to the clinical quality measure reporting requirements under the Medicare Electronic Health Record Incentive Program for eligible professionals who reported electronically through the PQRS portal. For MIPS, eligible clinicians need only report 6 quality measures for the quality performance category, except those reporting via the Web Interface, and there is no requirement to ensure that the measures span across 3 National Quality Strategy domains

40 Patient Relationship Codes In May 2017, CMS posted the operational list of patient relationship categories that are required under section 101(f) of MACRA. In this rule, we finalized certain Level II HCPCS modifiers to be used on claims to indicate these patient relationship categories. Further, we finalized a policy that the reporting of these HCPCS modifiers may be voluntarily by clinicians associated with these patient relationship categories beginning January 1, We anticipate that there will be a learning curve with respect to the use of these modifiers, and we will work with clinicians to ensure their proper use Medicare EHR Incentive Program For the Medicaid EHR Incentive Program, we specified (80 FR 62888) that states would continue to be responsible for determining whether and how electronic reporting of Clinical Quality Measures (CQMs) would occur, or if they wish to allow reporting through attestation. We maintained a requirement that EPs report 9 CQMs covering at least 3 National Quality Standard (NQS) domains (80 FR through 62889)

41 Medicare EHR Incentive Program We did not propose to change the requirements for EPs who reported CQMs through attestation because those who attested were successful; therefore, we believe there is no need to change the requirement. Additionally, the Registration and Attestation portal was phased out on October 1, 2017, and is no longer available for use Medicare Shared Savings Program CMS is finalizing several modifications to the rules for accountable care organizations (ACOs) participating in the Medicare Shared Savings Program. These modifications are designed to reduce burden and streamline program operations

42 Medicare Shared Savings Program The new policies include the following: Revisions to the assignment methodology for ACOs that include FQHCs and RHCs by eliminating the requirement to enumerate each physician working in the FQHC or RHC on the ACO participant list; Reduction of burden for ACOs submitting an initial Shared Savings Program application or the application for use of the skilled nursing facility (SNF) 3-Day Rule Waiver; and The addition of three new chronic care management codes (CCM) and four behavioral health integration (BHI) codes to the definition of primary care services used in the ACO assignment methodology Alignment with Other Medicare Quality Programs We have proposed in the CY 2018 Quality Payment Program proposed rule to develop a direct tie between MIPS and the AUC program. We proposed to give MIPS credit to ordering professionals for consulting AUC using a qualified Clinical Decision Support Mechanism (CDSM) as a high-weight improvement activity for the performance period beginning January 1,

43 Alignment with Other Medicare Quality Programs We believe this will incentivize early use of qualified CDSMs to consult AUC by motivated eligible clinicians looking to improve patient care and to better prepare themselves for the AUC program. Although the AUC program would not officially begin until January 1, 2019, we are able to support this proposed improvement activity because the first qualified CDSMs will be announced in conjunction with this proposed rule; therefore, ordering professionals will be able to begin consulting AUC using those tools Alignment with Other Medicare Quality Programs We also considered how the AUC program could serve to support a quality measure under the MIPS quality performance category, and sought feedback from the public regarding feasibility and value of pursuing this idea further

44 Alignment with Other Medicare Quality Programs We agree with recommendations that we work closely to align quality improvement mechanisms in the Medicare program. We recognize that there are further opportunities for alignment between the AUC program and the Quality Payment Program, but did not propose additional policies in rulemaking for CY Value Modifier In order to better align incentives and provide a smoother transition to the new Merit-based Incentive Payment System under the Quality Payment Program, we are finalizing the following changes to previously-finalized policies for the 2018 Value Modifier: Reducing the automatic downward payment adjustment for not meeting the criteria to avoid the PQRS adjustment from negative four percent to negative two percent (-2.0 percent) for groups of ten or more clinicians; and from negative two percent to negative one percent (-1.0 percent) for physician and non-physician solo practitioners and groups of two to nine clinicians;

45 2018 Value Modifier Holding harmless all physician groups and solo practitioners who met the criteria to avoid the PQRS adjustment from downward payment adjustments for performance under quality-tiering for the last year of the program; and Aligning the maximum upward adjustment amount to 2 times the adjustment factor for all physician groups and solo practitioners Value Modifier Given final policy changes for the Physician Quality Reporting System and the Value Modifier, we finalized that we will not report 2018 Value Modifier data in the Physician Compare downloadable database as this would be the first and only year such data would have been reported. However, to promote transparency we will continue to make available the Value Modifier public use and research identifiable files

46 2018 QUALITY PAYMENT PROGRAM FINAL RULE Final Rule Overview The Quality Payment Program, established by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), is a quality payment incentive program for physicians and other eligible clinicians, which rewards value and outcomes in one of two ways: Merit-based Incentive Payment System (MIPS) Advanced Alternative Payment Models (APMs)

47 Clinicians Have Two Tracks to Choose From Final Rule Overview As we go into the second year, referred to as The Quality Payment Program Year 2, we have been listening to feedback and using it to ensure that: The program s measures and activities are meaningful. Clinician burden is minimized. Care coordination is better. Clinicians have a clear way to participate in Advanced APMs

48 Final Rule Overview In Year 2, we are keeping many of the flexibilities from the transition year to help clinicians get ready for Year 3. The Quality Payment Program makes major changes to how Medicare pays clinicians. We ve heard challenges and concerns from stakeholders, so we will keep: Going slow while preparing clinicians for full implementation in year 3. Providing more flexibility to help reduce your burden. Offering new incentives for participation Patients Over Paperwork Excluding individual MIPS eligible clinicians or groups with less than or equal to $90,000 in Part B allowed charges or less than or equal to 200 Part B beneficiaries. We address extreme and uncontrollable circumstances, such as hurricanes and other natural disasters, for both the transition year and the 2018 MIPS performance period. Including virtual groups as another participation option for year 2. Making it easier for clinicians to qualify for incentive payments by participating in Advanced APMs that begin or end in the middle of a year

49 What s new in the Quality Payment Program Year 2? To help you be successful, we re going to keep looking for ways to reduce your burden and simplify the program. CMS is working to implement the Quality Payment Program in a way to provide flexibility and to reduce burden Quality Payment Program Year 2: MIPS Highlights We are keeping many of our transition year policies and making some minor changes including: Raising the performance threshold to 15 points in Year 2 (from 3 points in the transition year). Allowing the use of 2014 Edition and/or 2015 Certified Electronic Health Record Technology (CEHRT) in Year 2, and giving you a bonus for using only 2015 CEHRT. Giving up to 5 bonus points on your final score for treatment of complex patients

50 Quality Payment Program Year 2: MIPS Highlights Automatically weighting the Quality, Advancing Care Information, and Improvement Activities performance categories at 0% of the final score for clinicians impacted by hurricanes Irma, Harvey and Maria and other natural disasters. Adding 5 bonus points to the final scores of small practices More Options for Small Practices Tailored flexibilities for groups of 15 or fewer clinicians including: Excluding individual MIPS eligible clinicians or groups with less than or equal to $90,000 in Part B allowed charges or less than or equal to 200 Part B beneficiaries. Adding 5 bonus points to the final scores of small practices

51 More Options for Small Practices Giving solo practitioners and small practices the choice to form or join a Virtual Group to participate with other practices. Continuing to award small practices 3 points for measures in the Quality performance category that don t meet data completeness requirements. Adding a new hardship exception for the Advancing Care Information performance category for small practices Extreme and Uncontrollable Circumstances Over the past several months, numerous clinicians have been affected in many areas of the country due to Hurricanes Harvey, Irma, and Maria, which occurred during the 2017 MIPS performance period. We address extreme and uncontrollable circumstances for both the transition year and the 2018 MIPS performance period in this final rule with comment

52 Extreme and Uncontrollable Circumstances For the transition year, if a MIPS eligible clinician s CEHRT is unavailable as a result of extreme and uncontrollable circumstances (e.g., a hurricane, natural disaster, or public health emergency), the clinician may submit a hardship exception application to be considered for reweighting of the Advancing Care Information performance category. This application is due by December 31, This final rule with comment period extends this reweighting policy for the three other performance categories (Quality, Cost, and Improvement Activities) starting with the 2018 MIPS performance period. This hardship exception application deadline is December 31, Extreme and Uncontrollable Circumstances Because our policies relating to reweighting the Quality, Cost, and Improvement Activities performance categories are not effective until next year, we are issuing an interim final rule for automatic extreme and uncontrollable circumstances where clinicians can be exempt from these categories in the transition year without submitting a hardship exception application (note that cost has a 0% weight in the transition year)

53 What does that mean for 2017? Clinicians in affected areas that do not submit data will not have a negative adjustment. We know that the circumstances have created a significant hardship that has affected the availability and applicability of measures. Clinicians that do submit data will be scored on their submitted data. This allows them to be rewarded for their performance in MIPS. Because MIPS is a composite, clinicians have to submit data on two or more performance categories to get a positive payment adjustment What does that mean for 2017? The policy applies to individuals (not group submissions), but all individuals in the affected area will be protect for the 2017 MIPS performance period. We note that if a MIPS eligible clinician who is eligible for reweighting due to extreme and uncontrollable circumstances, but still chooses to report (as an individual or group), that they will be scored on that performance category based on their results. This policy does not apply to APMs

54 Virtual Groups We are excited to announce the inclusion of Virtual Groups as another participation option for year 2. A Virtual Group is a combination of 2 or more Taxpayer Identification Numbers (TINs) made up of solo practitioners and groups of 10 or fewer eligible clinicians who come together virtually (no matter specialty or location) to participate in MIPS for a performance period of a year APM Highlights This year s rule includes provisions to make it easier for eligible clinicians to participate in select APMs (known as Advanced APMs), which may allow them to qualify for incentive payments. Specific policies include: Extending the 8% generally applicable revenue based nominal amount standard that allows APMs to qualify as Advanced APM for two additional years, through performance year Exempting Round 1 Comprehensive Primary Care Plus participants certain currently participating clinicians from the 50 clinician limit on organizations that can earn incentive payments by participating in medical home models

55 APM Highlights Changing the requirement for Medical Home Models so that the minimum required amount of total financial risk increases more slowly. Making it easier for clinicians to qualify for incentive payments by participating in Advanced APMs that begin or end in the middle of a year Reducing Complexity We provided more detail on how eligible clinicians participating in selected APMs (known as MIPS APMs) will be assessed under the APM scoring standard. This special standard reduces burden for MIPS APM participants who do not qualify as Qualifying APM Participants (QPs), and are therefore subject to MIPS. We elaborated on how the All-Payer Combination Option will be implemented. This option allows clinicians to become QPs through a combination of Medicare participation in Advanced APMs and participation in Other Payer Advanced APMs. Where possible, we have created additional flexibilities and pathways to allow clinicians to be successful under the All Payer Combination Option. This option will be available beginning in performance year