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Confidential– Donotdistribute
HotTopicsInReimbursementQ22019
BobbiBuellMBA800-795-2633
[email protected]@yahoo.com
NEWSLETTER:www.onpointoncology.com
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Disclaimer
• Theinformationdescribedhereinissubjecttochangeasmanyofthedetailshereinaresubjecttointerpretation.
• CPTcodesanddescriptionsonlyarecopyright2019AmericanMedicalAssociation(AMA).Allrightsreserved.TheAMAassumesnoliabilityfordatacontainedornotcontainedherein.
• AllMedicareinformationisderivedfrompublishedrules;however,interpretationsmaybeerroneousandtyposmaybeevidenced.Itismandatorythatcodingandbillingisbasedoninformationderivedfromeachpracticeorclinic.
• Thisisnotlegalorpaymentadvice.• ThiscontentisabbreviatedforMedicalOncology.Itdoesnotsubstituteforathoroughreviewofcodebooks,regulations,andCarrierguidance.
• Thisinformationisvalidforthedateofpresentationonly.• Thispresentationshouldnotbereproducedwithoutthepermissionoftheauthorandistimesensitive
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AGENDA
• FINALPhysicianFeeScheduleRulefor2019• FINALHospitalOutpatientPaymentProgramRule2019• CPT/HCPCSCodes• PartC/PartDchanges• HCC(RiskAdjustment)Coding• Appendices
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WebSitesfor2019FINALRegulations
• Thispresentationisbasedonpublishedrules• PHYSICIANS:https://www.cms.govwww.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/• HOPPS:https:///Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices.html
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MedicarePhysicianPaymentBasics
• PaymentsarebasedonRVUsforeachcode(WRVUs+PERVUs+MalRVUs)• RVUsaremultipliedtimesGPCIsforyourgeographicallocation(W*WGPCI+PE*PEGPCI+Mal*MalGPCI)• TheMedicareconversionfactordeterminestheoveralllevelofMedicarepayments(W*WGPCI+PE*PEGPCI+Mal*MalGPCI)timesCF=$YourTotalAllowableforyourarea,whichwillbeinflated,deflated,orneutralizedbyyourQPPperformance.
W=Work;PE=PracticeExpense;MAL=ExpenseofMalpractice;RVUs=relativevalueunits
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CONVERSIONFACTORProposedfor2019
Source:PHYSICIANFINALFeeScheduleFINALRule2019,Table92
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FeeSchedule:DoesNotIncludeSequestration• Sequestration:
• Medicare2%acrosstheboardstartedonApril1,2013• Impactseverythingincludingdrugs• The2%comesoutoftheMedicareportion(80%)
• Drugsarepaidat104.304%ASP• Allpatientpaymentsexcluded
• Murray-RyanBudgetDealextendedtheSequesteruntil2023;PAMAextendeditto2024,andlastyear’sbudgetdealextendsitto2025.
Formoreaboutsequestration:https://www.nejm.org/doi/full/10.1056/NEJMp1303266?query=TOC&goback=.gde_917937_member_224781137&page=-33&sort=oldest
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PartBDrugChanges2019--
FINALIZED
• CMSbelievesthatdrugsarepaidtoohighlyatlaunch.
• StartingJanuary1,willpareWACplus6%toWAC3%fortheperiodbeforethedevelopmentofAverageSalesPrice.
• Questionforproviders—whatpercentageofyournewdrugsarepaidusinginvoicesversusarepaidonWACduringthelaunchperiod?
Formoreinformation,seepage667,DisplayCopy.2019FinalRule
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AppropriateUseCriteriaforAdvancedImaging
• Inthe2019proposedrule,CMSreaffirmedtheJanuary1,2020mandatoryconsultationdate,withaone-yeareducationandoperationstestingperiod.Thishasbeenintheregulationsfor5years.
• Inordertomeetthisdeadline,CMSrecommendsuseofaseriesofG-codesandmodifierforclaimsprocessing.Theagencynotesthatitwillconsiderfutureopportunitiestouseauniqueconsultationidentifier(UCI)forclaimsprocessingandwillcontinuetoengagewithstakeholdersonthistopic.
• CMSaddedindependentdiagnostictestingfacilities(IDTFs)tothedefinitionof"applicablesetting"fortheAUCprogram.Otherapplicablesettingsincludeaphysician'soffice,ahospitaloutpatientdepartment(includinganemergencydepartment)andanambulatorysurgicalcenter.
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RadiologyAssistants
• “AfterconsiderationofthesecommentsontheRFI,aswellasinformationprovidedbystakeholders,weproposedtoreviseourregulationstospecifythatalldiagnosticimagingtestsmaybefurnishedunderthedirectsupervisionofaphysicianwhenperformedbyanRAinaccordancewithstatelawandstatescopeofpracticerules.• StakeholdersrepresentingtheradiologycommunityhaveprovideduswithinformationshowingthattheRAdesignationincludesregisteredradiologistassistants(RRAs)whoarecertifiedbyTheAmericanRegistryofRadiologicTechnologists,andradiologypractitionerassistants(RPAs)whoarecertifiedbytheCertificationBoardforRadiologyPractitionerAssistants.• Weproposedtoreviseourregulationat¤410.32toaddanewparagraph(b)(4)tostatethatdiagnostictestsperformedbyanRRAoranRPArequireonlyadirectlevelofphysiciansupervision,whenpermittedbystatelawandstatescopeofpracticeregulations.“
FinalRule,DisplayCopy,page186
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E/MChanges2019:ChoosingtheAppropriateCode andProvidingSupporting Documentation
• ForcodingandbillingthePFS,practitionersmayuseeitherthe1995or1997E/Mdocumentationguidelines.TheseareverysimilartoaparallelsetofguidelinespresentintheCPTcodebook.
• Theseguidelinesspecifymedicalrecordinformationwithineachofthe threecomponentsthatservesassupportforbillingagivenvisit level—thehistory,physical,andmedicaldecision-making
CPTcodes,descriptionsandotherdataonlyarecopyright2017AmericanMedicalAssociation.Allrightsreserved.CPTisaregisteredtrademarkoftheAmericanMedicalAssociation (AMA). 6
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E/M2019:Why Change?• StakeholdershavesaidthattheE/Mdocumentationguidelines,andthecode
setitselfareclinicallyoutdatedandmaynotreflectthemostclinicallymeaningful orappropriatedifferencesinpatientcomplexityandcare.Furthermore,theguidelinesmaynotbereflectiveofchangesintechnology,orinparticular,thewaythatelectronicmedicalrecordshavechangeddocumentationandthepatient'smedical record.
• Accordingtostakeholders,someaspectsofrequireddocumentationareredundant
• WithEMRs,thereistoomuchcuttingandpastingtomeetrequirements.
• Additionally,currentdocumentationrequirementsmaynotaccountforchangesincaredelivery,suchasagrowingemphasisonteam-basedcare,increasesinthenumberofrecognizedchronicconditions,orincreasedemphasisonaccesstobehavioralhealth care.
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Final Policies for E/M Visits Starting in2019For2019andbeyond,CMSfinalizedthefollowingoptionalbutbroadly supporteddocumentationchangesforE/Mvisits,thatdonotrequirechangesincoding/payment.• Eliminationoftherequirementtodocumentthemedicalnecessityofahome
visitinlieuofanoffice visit;• Forhistoryandexamforestablishedpatientoffice/outpatientvisits,when
relevantinformationisalreadycontainedinthemedicalrecord,• practitionersmaychoosetofocustheirdocumentationonwhathas
changedsincethelastvisit,oronpertinentitemsthathavenotchanged,
• andneednotre-recordthedefinedlistofrequiredelementsifthereisevidencethatthepractitionerreviewedthepreviousinformationandupdateditas needed.
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Final Policies for E/M VisitsStarting in 2019• Additionally,weareclarifyingthatforchiefcomplaintandhistoryfornewand
establishedpatientoffice/outpatientvisits,• practitionersneednotre-enterinthemedicalrecordinformationthat
hasalreadybeenenteredbyancillary stafforthebeneficiary.• Thepractitionermaysimplyindicateinthemedicalrecordthatheorshe
reviewedandverifiedthis information.
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E/M2019:TeachingPhysicians
• Asageneralrule,Medicareregulationshistoricallyhaverequiredteachingphysiciansto• (1)bepresentatthetimeaserviceisfurnished,and• (2)personallydocumenttheirparticipationintheprovisionofE/Mservices.42C.F.R.§ 415.172(b)(2018).• Anexceptionforlow- andmid-levelcomplexityE/Mservicesfurnishedinoutpatientdepartmentsofteachinghospitals(orotherambulatorycaresettingsforwhichteachinghospitalsareeligibletoreceiveGMEreimbursement)permitsexperiencedmedicalresidentstoperformcertainE/Mservicesoutsidethedirectpresenceoftheteachingphysician,butalsohasrequired—untilnow—theteachingphysiciansthemselvesto"documenttheextentof[hisorher]participationinthereviewanddirectionoftheservices."42C.F.R.§ 415.174(a)(3)(v)(2018).
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E/M2019:TeachingPhysicians
• IntheCY2019MPFSFinalRule,CMShasremovedtherequirementthatdocumentationoftheteachingphysician'sparticipationintheE/Mservicetobeenteredpersonallybytheteachingphysician.Medicareregulationsarerevised,effectiveJanuary1,2019,toprovideexpresslythatwhilesuchdocumentationstillisrequired,the"extentoftheteachingphysician'sparticipation[inanE/Mservicefurnishedbyaresidentintheoutpatientdepartmentofateachinghospital]maybedemonstratedbythenotesinthemedicalrecordsmadebyaphysician,resident,ornurse."42C.F.R.§ 415.174(a)(6)(2019).• Theseregulatorychangesareconsistentwith,andbuildupon,revisionsearlierthisyeartotheMedicareClaimsProcessingManual,whereinCMSreviseddocumentationrulesto permitteachingphysicianstoverify,ratherthanhavingtore-document,medicalrecordnotationsenteredbymedicalstudents whoassistintheperformanceofabillableE/Mservice.• Again,thisisforlowtomoderatecomplexityservices.
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AdvancingVirtual Care• In response to the CY 2018 PFS Proposed Rule, CMS received feedback fromstakeholders supportive of CMS expanding access to services that utilizetechnological developments in healthcare.
• CMSis interestedinrecognizingchangesinhealthcarepracticethatincorporateinnovationandtechnologyinmanagingpatient care.
• CMS aims toincreaseaccessforMedicarebeneficiariestotheseservicesthatareroutinelyfurnishedviacommunicationtechnologybyclearlyrecognizingadiscretesetofservicesthataredefinedbyandinherentlyinvolvetheuseofcommunication technology.
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AdvancingVirtualCare(cont.)
Tosupportaccesstocareusingcommunicationtechnology,weare finalizingpolicies to:
• Paycliniciansforvirtualcheck-ins– brief,non-face-to-faceassessmentsviacommunication technology.
• Paycliniciansforremoteevaluationofpatient-submittedphotos orrecorded video.
• PayRuralHealthClinics(RHCs)andFederallyQualifiedHealthCenters(FQHCs)forthesekindsofservices- outsideoftheRHCall-inclusiverateandtheFQHCProspectivePaymentSystem rate.
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Technology-BasedServicesfor2019
• BriefCommunicationTechnology-BasedService,calleda"VirtualCheck-In"(HCPCScodeG2012),wouldbebillablewhenaphysicianorotherqualifiedhealthcareprofessional("QHCP")hasabriefnon-face-to-facecheck-inwithapatientviacommunicationtechnology,todeterminewhetherthepatient'sconditionnecessitatesanofficevisit.Theservicewouldhavea0.25workrelativevalueunit(RVU)andbedescribedwithaG-code,G2012(Briefcommunicationtechnology-basedservice,e.g.virtualcheck-in,byaphysicianorotherqualifiedhealthcareprofessional whocanreportevaluationandmanagementservices,providedtoanestablishedpatient,notoriginatingfromarelatedE/Mserviceprovidedwithintheprevious7daysnorleadingtoanE/Mserviceorprocedurewithinthenext24hoursorsoonestavailableappointment;5-10minutesofmedicaldiscussion).• Evaluationofpre-recordedinformation:ThesecondproposednewserviceisRemoteEvaluationofPre-RecordedPatientInformation(HCPCSCodeG2010),whichwouldallowpractitionerstobepaidseparatelyforreviewingpatient-transmittedphotoorvideoinformationtoassesswhetheravisitisneeded. Page66,DisplayCopy,ProposedRuleandPage108,DisplayCopy,FinalRule
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Technology-BasedServicesMedicarewillpayfortheseservicesin2019BUTREADTHECPTDESCRIPTORS!!• CPT99446:Inter-professionaltelephone/Internetassessmentandmanagementserviceprovidedbyaconsultativephysicianincludinga verbalandwrittenreporttothepatient'streating/requestingphysicianorotherqualifiedhealthcareprofessional;5-10minutes ofmedicalconsultativediscussionandreview
• CPT99447:Sameas99446,but11-20minutes ofmedicalconsultativediscussionandreview
• CPT99448:Sameas99446,but21-30minutes ofmedicalconsultativediscussionandreview
• CPT99449:Sameas99446,but31minutesormore ofmedicalconsultativediscussionandreview
• CPT99451:Inter-professionaltelephone/Internet/electronichealthrecordassessmentandmanagementserviceprovidedbyaconsultativephysicianincludingawrittenreporttothepatient’streating/requestingphysicianorotherqualifiedhealthcareprofessional,5ormoreminutes ofmedicalconsultativetime
• CPT99452:Inter-professionaltelephone/Internet/electronichealthrecordreferralservice(s)providedbyatreating/requestingphysicianorqualifiedhealthcareprofessional,30minutes
• Patientmustconsenttocost
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TelehealthServices—Additionsfor2019--FINAL
• CMSwilladdmobilestrokeunits,renaldialysisfacilitiesandthehomesofESRDbeneficiariesreceivinghomedialysistothedefinitionof"originatingsite."
• Also,theyadded:telehealthservicesbeginninginCY2019onacategory1basis:• HCPCScodeG0513(Prolongedpreventive
service(s)(beyondthetypicalservicetimeoftheprimaryprocedure),intheofficeorotheroutpatientsettingrequiringdirectpatientcontactbeyondtheusualservice;first30minutes(listseparatelyinadditiontocodeforpreventiveservice)and
• HCPCScodeG0514:(Prolongedpreventiveservice(s)(beyondthetypicalservicetimeoftheprimaryprocedure),intheofficeorotheroutpatientsettingrequiringdirectpatientcontactbeyondtheusualservice;eachadditional30minutes(listseparatelyinadditiontocodeG0513foradditional30minutesofpreventiveservice).
StartsonPage63,DisplayCopy,ProposedRule
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Evaluation&ManagementServices:CompleteOverhaulProposal=2021• Overview
• Thisproposal,whichwasdelayeduntil2021,appliesONLYtoofficevisits—NewandEstablished
• Visitsnowarebasedoncriteriaestablishedin1995and1997—history,physical,medicaldecision-making,etc.
• Proposalfor2021• Visitscanbecodedbasedononeofthreedeterminants
• Currentcriteriafor99212orallcodes• Timeforthecode• MedicalDecision-making
• Add-onsfor• PrimaryCare• Specialists• ProlongedServices(differentfromCPT)
Startsonpage537,DisplayCopy,FINALRule
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PoliciesforE/MOffice/OutpatientVisitsStartingin 2021
• BeginninginCY2021,CMSwillimplementpayment,coding,andadditionaldocumentationchangesforE/Moffice/outpatientvisits, specifically:o Singleratesforlevels2through4forestablishedandnewpatients,
maintainingthepaymentratesforE/Moffice/outpatientvisitlevel5inordertobetteraccountforthecareandneedsofcomplex patients;
o Add-oncodesforlevel2through4visitsthatdescribetheadditionalresourcesinherentinvisitsforprimarycareandparticularkindsofnon-proceduralspecializedmedical care;
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SpecialtyAdditionalPayments(2021)
• Visitcomplexityinherenttoevaluationandmanagementassociatedwithnonproceduralspecialtycareincludingendocrinology,rheumatology,hematology/oncology,urology,neurology,obstetrics/gynecology,allergy/immunology,otolaryngology,interventionalpainmanagement,cardiology,nephrology,infectiousdisease,psychiatry,andpulmonology.(Add-oncode,listseparatelyinadditiontolevel2through4office/outpatientevaluationandmanagementvisit,neworestablished)
Page370,DisplayCopy,ProposedRule
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PrimaryCarePayments(2021)
• AG-codewillbeestablishedthatcanbebilledwithanyprimarycareestablishedpatientE&MvisittoaddadditionalRVUstothepaymenttoaccountfortheadditionalresourcesofthecognitiveworkofprimarycarephysiciansORofspecialistsworkingasthepatient'sprimarycarephysicianatthattime.Visitcomplexityinherenttoevaluationandmanagementassociatedwithprimarymedicalcareservicesthatserveasthecontinuingfocalpointforallneededhealthcareservices(Add-oncode,listseparatelyinadditiontolevel2through4office/outpatientevaluationandmanagementvisit,neworestablished)
This image cannot currently be displayed.
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AdditionalE/MAdjustments
• CMSisfinalizingacodingandpaymentpolicytoaccountfortheadditionalresourcesrequiredwhenpractitionersneedtospendextendedtimewiththeirpatientsduringaparticularE/Moffice/outpatientlevel2through4visits,regardlessofthekindofcarethepractitionerisfurnishingorwhetherornotthemedicalcomplexityofthevisitisthedeterminingfactorforthelengthofvisit.ThereisanexpectationthatSpecialistswithhighnumbersofLevel4sand5swillusethiscode.(Page614,DisplayCopy,FinalRule)• “ForCY2021,CMSbelievesthat30additionalminutes(which,inaccordancewithCPTcodingconventionsfortimedcodes,canbereportedafter15additionalminutesisspentwiththepatient)isanappropriateintervaloftimeafterwhichtoreflecttheadditionalresourcecostsassociatedwithpatientvisitsthatrequiremoretimethanistypicalforthevisit.”Thiswillbepaidatapproximately50%ofa99354.Page619,DisplayCopy,FinalRule
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PoliciesforE/MOffice/OutpatientVisitsStartingin2021(cont.)o Anew“extendedvisit”add-oncodeforlevel2through4visitstoaccountfortheadditionalresourcesrequiredwhenpractitionersneedtospendadditionaltimewith patients.
o Forlevel2through5visits,choicetodocumentusingthecurrentframework,MDMor time;▪ Whentimeisusedtodocument,practitionerswilldocumentthemedicalnecessityofthevisitandthatthebillingpractitionerpersonallyspenttherequiredamountoftimeface-to-facewiththebeneficiary(typicalCPTtimeforcodereported,plusanyextended/prolonged time).
▪ WhenusingcurrentframeworkorMDMtodocument,forlevel2through4visitsCMSwillonlyrequirethesupportingdocumentationcurrently associatedwithLevel2visits.
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DocumentingUsing Time
31
Code(s) Required Time(minutes)
Estimated Payment
99212 10 $90
99213 15 $90
99214 25 $90
99215 40 $148
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DocumentingUsingTime (cont.)
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Code(s) Required Time(minutes)
Estimated Payment
99212extended(99212+ GPRO1) 34-69 $157
99213 extended(99213+GPRO1) 34-69 $157
99214 extended(99214+GPRO1) 34-69 $157
99215 prolonged(99215+ 99354-5) 70+ $281+
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EstimatedPaymentBeginning2021forOffice/OutpatientE/MVisits
*CurrentPaymentforCY 2018**EstimatedPaymentbasedontheCY2019finalizedrelativevalueunitsandtheCY2018payment rate 33
Level Current
Payment*
(established
patient)
EstimatedPaymentbeginning2021**
1 $22 $242 $45 $90($103for primary
careandnon-proceduralcare)
3 $744 $109
5 $148 $148
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RealMedicalOncologyNumbersProjections2019versus2021
E/MVolume=focalPoint®2018PaidMedicareClaims
Code Payer
Paid Claim Count With No -25 Price 2019 Price 2021
Price 2021 w/add-on Total 2019
Total 2021 Without Add-on Total 2021 With Add on
99201 Medicare 71 $46 $46 $46 3,300.79$ 3,300.79$ 3,300.79$ 99202 Medicare 931 $77 $130 $143 72,133.88$ 121,030.00$ 133,133.00$ 99203 Medicare 9,604 $110 $130 $143 1,055,671.68$ 1,248,520.00$ 1,373,372.00$ 99204 Medicare 38,964 $167 $130 $143 6,501,533.04$ 5,065,320.00$ 5,571,852.00$ 99205 Medicare 52,526 $210 $210 $210 11,017,328.50$ 11,017,328.50$ 11,017,328.50$ TOTAL 18,649,967.89$ 17,455,499.29$ 18,098,986.29$ 99211 Medicare 45,223 $23 $24 $24 1,043,294.61$ 1,085,352.00$ 1,085,352.00$ 99212 Medicare 23,438 $46 $90 $103 1,072,757.26$ 2,109,420.00$ 2,414,114.00$ 99213 Medicare 445,227 $75 $90 $103 33,534,497.64$ 40,070,430.00$ 45,858,381.00$ 99214 Medicare 761,767 $110 $90 $103 84,007,664.76$ 68,559,030.00$ 78,462,001.00$ 99215 Medicare 105,952 $148 $148 $148 15,655,467.52$ 15,655,467.52$ 15,655,467.52$ TOTAL 135,313,681.79$ 127,479,699.52$ 143,475,315.52$
Total All Codes 153,963,649.68$ 144,935,198.81$ 161,574,301.81$
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CareCoordinationintheOCM
Notethatnon-OCMpractitionersmaybillfortheseservicesforOCMbeneficiariesduringmonthsthatOCMpractitionersbilltheMEOS.TheMEOScannotbebilledafterbeneficiarieshavediedorenteredhospice
OCMpractitionerscannotbillforthefollowingcarecoordinationservicepaymentsforOCMbeneficiariesforthemonthsthattheybilltheMEOS:•
ChronicCareManagement(CCM)•
TransitionalCareManagement(TCM)•HomeHealthCare
Supervision
HospiceCareSupervision EndStageRenalDisease(ESRD)
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InvestigatingAdditionalE/MServices
• Noticeforeachoftheseservicesthefollowing:• Reimbursementversusextrawork• Periodrequirements• Encountertimeframe• FollowUptimeframe• FTFversusVirtual• Whocanperform:MD/DO,NPP,Staff• Consent• CCIedits
• Traintothedocumentationrequirementsabove• InstallEMRtemplates
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ForFurther Information
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SeethePhysicianFeeSchedulewebsite at:https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/PhysicianFeeSched/index.html
SeetheMIPswebsiteat:https://qpp.cms.gov
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Statusof340BMedicarePricing
• Non-pass-throughdrugspurchasedunder340BpricingarepricedatASPMINUS22.5%.• However,inlateDecember,aconsortiumofhospitalgroupssuedCMSstatingthatCMShad‘oversteppeditsauthority’.• Thislawsuitisstillwendingitswaythroughthecourts.But,thebottomlineisthatASPminus22.5%maynotstandfor2019.
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2019HOPPSDrugPayments
Atlaunch,drugsandbiologicalproductsthatdonothavepass-throughpaymentstatusatwholesaleacquisitioncost(WAC)+3percentinsteadofWAC+6percent.IfWACdataarenotavailableforadrugorbiologicalproduct,weareproposingtocontinueourpolicytopayseparatelypayabledrugsandbiologicalproductsat95percentoftheaveragewholesaleprice(AWP).
Alldrugswhosecostis$125orlessperencounter,accordingtoCMS,willbebundledintotheAPC.Thisa$5increasefromlastyear—lessthantheusual$10increase
Paynon-pass-throughbiosimilarsacquiredunderthe340BprogramatASPminus22.5percentofthebiosimilar’sownASPratherthanASPminus22.5percentofthereferenceproduct’sASP(maybe—lawsuit).
DisplayCopyProposedHospitalOutpatientRule,page274;FinalRule,DisplayCopy,page23
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FacilityFees:Controlof“UnnecessaryServices”
• ThispolicywouldresultinlowercopaymentsforbeneficiariesandsavingsfortheMedicareprograminanestimatedamountof$380millionfor2019,• Firstyearofatwoyearphase-in(2019)• ForanindividualMedicarebeneficiary,currentMedicarepaymentfortheclinicvisitfurnishedinanexceptedoff-campusPBDisapproximately$116with$23beingtheaveragebeneficiarycopayment.
• ThepolicytoadjustthispaymenttothePFSequivalentratewouldreducetheOPPSpaymentratefortheclinicvisitto$81withabeneficiarycopaymentof$16(basedonatwoyearphase-in),thussavingbeneficiariesanaverageof$7eachtimetheyvisitanoff-campusdepartmentinCY2019
https://www.cms.gov/newsroom/fact-sheets/cms-finalizes-medicare-hospital-outpatient-prospective-payment-system-and-ambulatory-surgical-center
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Section603:Paymentfor2018-2019
Theseentitieswillstillbepaidat40%of
theHOPPSrate
•Thisdoesnotincludedrugsorlabs
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Section603:Non-ExceptedFacilities
• BeginningJanuary1,2018,MedicarepaysanadjustedamountoftheASPminus22.5%forcertainseparatelypayabledrugsorbiologicalsthatareacquiredthroughthe340BProgrambyahospitalpaidundertheOPPSthatisnotexceptfromthepaymentadjustmentpolicy.ForCY2018,ruralsolecommunityhospitals(SCHs),children’shospitals,andPPS-exemptcancerhospitalsareexceptedfromthe340Bpaymentadjustment.• IntheCY2018OPPS/ASCfinalrulewithcommentperiod,afewcommentersraisedthatthe340Breductionwouldnotapplytonon-exceptedoff-campusPBDsandsharedtheirviewthatthiscouldresultinbehavioralchangesthatmayundermineCMS’policygoalsofreducingbeneficiarycost-sharingliability.Thisyear,CMSwastoadoptapolicytopayASPminus22.5%for340B-acquireddrugsfurnishedbynon-exceptedoff-campusprovider-baseddepartments.340Bdrugpaymentiscurrentlythesubjectofalawsuitandwillchange.
DisplayCopy,ProposedHospitalOutpatientRule,page387
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CancerHospitalAdjustments
• CancerHospitalPaymentAdjustment:ForCY2019,CMSwillcontinuetoprovideadditionalpaymentstocancerhospitalssothatthecancerhospital’spayment-to-costratio(PCR)aftertheadditionalpaymentsisequaltotheweightedaveragePCRfortheotherOPPShospitalsusingthemostrecentlysubmittedorsettledcostreportdata.However,section16002(b)ofthe21stCenturyCuresActrequiresthatthisweightedaveragePCRbereducedby1.0percentagepoint.Basedonthedataandtherequired1.0percentagepointreduction,weareproposingthatatargetPCRof0.88wouldbeusedtodeterminetheCY2019cancerhospitalpaymentadjustmenttobepaidatcostreportsettlement.Thatis,thepaymentadjustmentswouldbetheadditionalpaymentsneededtoresultinaPCRequalto0.88foreachcancerhospital.
DisplayCopy,ProposedHospitalOutpatientRule,page2andDisplayCopy,FinalRule,page24
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PriceTransparency2019
• CMSsayssupplierscanandshouldberequiredtoinformpatientsaboutchargesandpaymentinformationforhealthcareservicesandout-of-pocketcosts,whatdataelementsthepublicwouldfindmostuseful,andwhatotherchangesareneededtoempowerpatients.• Somehospitalshavereleasedtheirfeeschedulesand/orChargemasters
DisplayCopy,ProposedHospitalOutpatientRule,page638
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PaymentUpdatefor
APCs
• CMShistoricallyupdatedASC(AmbulatorySurgeryCenters)paymentratesannuallybythepercentageincreaseintheConsumerPriceIndexforallurbanconsumers(CPI-U).IntheCY2018OPPS/ASCproposedrule,CMSsolicitedrecommendationsandideasonASCpaymentsystemreform.FortheCY2019OPPS/ASCproposedrule,inresponsetothecommentsreceived,CMSproposedtoupdateASCpaymentratesusingthehospitalmarketbasketratherthantheCPI-UforCY2019throughCY2023.WealsosoughtcommentonanalternativeproposaltomaintainCPI-Uwhilecollectingevidencetojustifyadifferentpaymentupdate,oradoptingthenewproposedpaymentupdatebasedonthehospitalmarketbasketpermanently.
• Wearefinalizingthisproposalwithoutmodification.Usingthehospitalmarketbasket,CMSisupdatingASCratesforCY2019by2.1percent.Thechangeisbasedonthehospitalmarketbasketincreaseof2.9percentminusa0.8percentagepointadjustmentforMFP. Thischangewillhelptopromote“site-neutrality”betweenhospitalsandASCsandencouragethemigrationofservicesfromthehospitalsettingtothelowercostASCsetting.
CMSOutpatientFactSheethttps://www.cms.gov/newsroom/fact-sheets/cms-finalizes-medicare-hospital-outpatient-prospective-payment-system-and-ambulatory-surgical-center
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HospitalQualityProgram• CMSisnotfinalizingremovaloftwoofthetenmeasuresproposedforremoval.IntheCY2019OPPS/ASCfinalrule,CMSisfinalizingpoliciesto:• UpdatetheCodeofFederalRegulationstoretainmeasuresfromapreviousyear’sHospitalOQRProgrammeasuresetfor
subsequentyears’measuresets.• UpdatetheCodeofFederalRegulationstousetheregularrulemakingprocesstoremoveameasureforcircumstancesthat
donotraisespecificpatientsafetyconcerns.• UpdatetheCodeofFederalRegulationstoimmediatelyremovemeasuresasaresultofpatientsafetyconcerns.• RemoveonequalitymeasurebeginningwiththeCY2020paymentdeterminationandsevenqualitymeasuresbeginning
withtheCY2021paymentdetermination.WenotethatwearenotfinalizingourproposalstoremovetheAppropriateFollow-UpIntervalforNormalColonoscopyinAverageRiskPatients(OP-29)andtheCataracts:ImprovementinPatient’sVisualFunctionwithin90DaysFollowingCataractSurgery(OP-31)measures.
• ExtendthereportingperiodfromonetothreeyearsforOP-32: FacilitySeven-DayRisk-StandardizedHospitalVisitRateafterOutpatientColonoscopybeginningwiththeCY2020paymentdeterminationandforsubsequentyears.
• UpdatetheCodeofFederalRegulationsthefactorstobeconsideredwhenremovingmeasuresfromtheprogramandcodifymeasureremovalpolicies.
• ChangethefrequencyoftheHospitalOQRProgramSpecificationsManualreleasebeginningwithCY2019andforsubsequentyearssuchthattheywillbereleasedonceeverytwelvemonthswithaddendaasnecessary– amodificationfromwhatwasproposed.
• Updaterequirementsrelatedtoparticipationstatus,includingremovaloftheNoticeofParticipationformforthefortheCY2020paymentdetermination
CMSFactSheet:FinalRuleHospitalOutpatientProspectivePayment2019
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MedicareHOPPSPaymentVersusOfficePaymentforDrugAdministration(NationalRates)
Code Brief Description PFS2018 PFS2019
APC2018 APC2019
96361 Hydrationover30minutes,separate
$14.04 $13.69 $37.03 $37.88
96367 Therapeutic infusion,separate&seq
$32.04 $31.71 $58.20 $59.75
96372 Therapeuticinjection $20.88 16.72 $58.20(Q1)
$59.75(Q1)
96413 Chemotherapy,initialinfusion $144.72 $143.08 $297.54 $288.38
96417 Chemotherapy infusion,separate&sequential
$69.48 $69.20 $58.20 $59.75
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5151
EvaluationandManagement– ChangesOverview• Therearesixnew codesintheEvaluationandManagement(E&M)sectioninCPT.• GuidelineswererevisedforInter-professionalTelephone/Internet/ElectronicHealthRecordConsultationstoensurethatnewcodesarefacilitated.
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5252EvaluationandManagement99451and99452– ElectronicRecordAssessment/Consultative
Services• Inter-professionaltelephone/Internet/electronichealthrecordassessmentandmanagementserviceprovidedbyaconsultativephysician,includingawrittenreporttothepatient’streating/requestingphysicianorotherqualifiedhealthcareprofessional,5minutesormoreofmedicalconsultativetime.• Consultativeservicelastingmorethan5minutesandrequiresonlyawrittenreporttotherequestingphysician.
• Thiswasaddedrecognizingthatoralcommunicationsdonotalwaysoccurbetweenhealthcareprofessionalsandmayfacilitateconsultativeservicesingeographicareaswithnospecialistsavailable.
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5353EvaluationandManagement99453and99454– RemotePhysiologicMonitoringServices
• 99453 – Remotemonitoringofphysiologicalparameter(s)(e.g.,weight,bloodpressure,pulseoximetryrespiratoryflowrate,initial;setup,patienteducationonuseofequipment• 99454 - Remotemonitoringofphysiologicalparameter(s)(e.g.,weight,bloodpressure,pulseoximetryrespiratoryflowrate,initial;device(s)supply,withdailyrecording(s)orprogrammedalert(s)transmission,each30days.
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5454
EvaluationandManagement99457– RemotePhysiologicMonitoringServices
• 99457 - Remotephysiologicmonitoringtreatmentmanagementservices,20minutesormoreofclinicalstaff/physician/otherqualifiedhealthcareprofessionaltimeinacalendarmonthrequiringinteractivecommunicationwiththepatient/caregiverduringthemonth
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555599491– ChronicCareManagement(PersonallyPerformedbyProvider)
•WhenServicesarepersonallyperformedbyaphysicianorotherqualifiedhealthcareprofessional,atleast30minutesofphysicianorotherqualifiedhealthcareprofessionaltime,percalendarmonth.•Majordifferencebetweenthisandthe99490 CCMservicescodeiswhentheproviderpersonallyperformsthedifferenceintimewouldbe30minutes.Comparedto20minutesforclinicalstaff
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5656
CentralLines
• Centralvenousaccessrevisions– Thechangestotheperipherallyinsertedcentralcatheter(PICC)codesarethestarsofthissection,butdon’toverlookguidanceunderthecentralvenousaccessproceduressubsection.TheCPT2019nowstatesthatitisappropriatetocodeaPICClinewhenasaphenousveinistheinsertionsite.
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5757
CentralLines
• Therearealsomoredetailedguidelinesforreportingfluoroscopiccentralvenouscathetercode77001 and76937• 36584- reviseddescription nowincludesimageguidancenew(Replacement,complete,ofaperipherallyinsertedcentralvenouscatheter[PICC],withoutsubcutaneousportorpump,throughsamevenousaccess,includingallimagingguidance,imagedocumentation,andallassociatedradiologicalsupervisionandinterpretationrequiredtoperformthereplacement)
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5858CentralLines
• 36572 - Insertionofperipherallyinsertedcentralvenouscatheter[PICC],withoutsubcutaneousportorpump,includingallimagingguidance,imagedocumentation,andallassociatedradiologicalsupervisionandinterpretationrequiredtoperformtheinsertion;(youngerthan5yearsofage)• 36573 - (…;age5yearsorolder)• 36572-36573arenumericallyoutoforderandarebelow36572inthebook
Note: ChestX-raycodes(71045-71048)orotherimagingservicestodocumentthefinalcathetertippositionarebundledinto36584and36572-36573.However,whentheproviderusesimagingbutdoesnotconfirmthetip’slocation,thepracticeshouldappendmodifier52(Reducedservices)withthecode.
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5959
Vaccine
• 90689- Influenzavirusvaccinequadrivalent[IIV4],inactivated,adjuvanted,preservativefree,0.25mLdosage,forintramuscularuse)
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HCPCSCodeAdditions—Non-Cancer/SupportiveCare
C9462 Injection, delafloxacin, 1 mg Injection, delafloxacinJ0185 Injection, aprepitant, 1 mg Inj., aprepitant, 1 mgJ0517 Injection, benralizumab, 1 mg Inj., benralizumab, 1 mgJ0567 Injection, cerliponase alfa, 1 mg Inj., cerliponase alfa 1 mgJ0584 Injection, burosumab-twza 1 mg Injection, burosumab-twza 1mJ0599 Injection, c-1 esterase inhibitor (human), (haegarda), 10 units Inj., haegarda 10 unitsJ0841 Injection, crotalidae immune f(ab')2 (equine), 120 mg Inj crotalidae im f(ab')2 eqJ1301 Injection, edaravone, 1 mg Injection, edaravone, 1 mgJ1454 Injection, fosnetupitant 235 mg and palonosetron 0.25 mg Inj fosnetupitant, palonosetJ1628 Injection, guselkumab, 1 mg Inj., guselkumab, 1 mgJ1746 Injection, ibalizumab-uiyk, 10 mg Inj., ibalizumab-uiyk, 10 mgJ2062 Loxapine for inhalation, 1 mg Loxapine for inhalation 1 mgJ2797 Injection, rolapitant, 0.5 mg Inj., rolapitant, 0.5 mgJ3245 Injection, tildrakizumab, 1 mg Inj., tildrakizumab, 1 mg
J3304Injection, triamcinolone acetonide, preservative-free, extended-release, microsphere formulation, 1 mg Inj triamcinolone ace xr 1mg
J3316 Injection, triptorelin, extended-release, 3.75 mg Inj., triptorelin xr 3.75 mgJ3397 Injection, vestronidase alfa-vjbk, 1 mg Inj., vestronidase alfa-vjbkJ3398 Injection, voretigene neparvovec-rzyl, 1 billion vector genomes Inj luxturna 1 billion vec gJ3591 Unclassified drug or biological used for esrd on dialysis Esrd on dialysi drug/bio nocJ7170 Injection, emicizumab-kxwh, 0.5 mg Inj., emicizumab-kxwh 0.5 mgJ7177 Injection, human fibrinogen concentrate (fibryga), 1 mg Inj., fibryga, 1 mg
J7203Injection factor ix, (antihemophilic factor, recombinant), glycopegylated, (rebinyn), 1 iu Factor ix recomb gly rebinyn
J7318Hyaluronan or derivative, durolane, for intra-articular injection, 1 mg Inj, durolane 1 mg
J7329 Hyaluronan or derivative, trivisc, for intra-articular injection, 1 mg Inj, trivisc 1 mg
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HCPCSCodeAdditions-Cancer/BiosimilarDrugsJ7329 Hyaluronan or derivative, trivisc, for intra-articular injection, 1 mg Inj, trivisc 1 mgJ9044 Injection, bortezomib, not otherwise specified, 0.1 mg Inj, bortezomib, nos, 0.1 mgJ9057 Injection, copanlisib, 1 mg Inj., copanlisib, 1 mgJ9153 Injection, liposomal, 1 mg daunorubicin and 2.27 mg cytarabine Inj daunorubicin, cytarabineJ9173 Injection, durvalumab, 10 mg Inj., durvalumab, 10 mgJ9229 Injection, inotuzumab ozogamicin, 0.1 mg Inj inotuzumab ozogam 0.1 mgJ9311 Injection, rituximab 10 mg and hyaluronidase Inj rituximab, hyaluronidaseJ9312 Injection, rituximab, 10 mg Inj., rituximab, 10 mgQ5103 Injection, infliximab-dyyb, biosimilar, (inflectra), 10 mg Injection, inflectraQ5104 Injection, infliximab-abda, biosimilar, (renflexis), 10 mg Injection, renflexis
Q5105Injection, epoetin alfa, biosimilar, (retacrit) (for esrd on dialysis), 100 units Inj retacrit esrd on dialysi
Q5106Injection, epoetin alfa, biosimilar, (retacrit) (for non-esrd use), 1000 units Inj retacrit non-esrd use
Q5107 Injection, bevacizumab-awwb, biosimilar, (mvasi), 10 mg Inj mvasi 10 mgQ5108 Injection, pegfilgrastim-jmdb, biosimilar, (fulphila), 0.5 mg Injection, fulphilaQ5109 Injection, infliximab-qbtx, biosimilar, (ixifi), 10 mg Injection, ixifi, 10 mgQ5110 Injection, filgrastim-aafi, biosimilar, (nivestym), 1 microgram NivestymHCPCS/MODCodeAction LongDescriptor ShortDescriptorEffectiveDate
Q5111 ADD Injection,Pegfilgrastim-cbqv,biosimilar,(udenyca),0.5mg. Injection,udenyca0.5mg1/1/19
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ChangedHCPCSCodesQ9992
Injection, buprenorphine extended-release (sublocade), greater than 100 mg Buprenorphine xr over 100 mg
J0834 Injection, cosyntropin, 0.25 mg Inj., cosyntropin, 0.25 mg
J7178Injection, human fibrinogen concentrate, not otherwise specified, 1 mg Inj human fibrinogen con nos
J8655 Netupitant 300 mg and palonosetron 0.5 mg, oral Oral netupitant, palonosetroJ9041 Injection, bortezomib (velcade), 0.1 mg Inj., velcade 0.1 mgK0037 High mount flip-up footrest, each Hi mount flip-up footrest ea
Q2041
Axicabtagene ciloleucel, up to 200 million autologous anti-cd19 car positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose Axicabtagene ciloleucel car+
Q4133Grafix prime, grafixpl prime, stravix and stravixpl, per square centimeter Grafix stravix prime pl sqcm
Q4137 Amnioexcel, amnioexcel plus or biodexcel, per square centimeter Amnioexcel biodexcel 1sq cm
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DeletedHCPCSCodesQ4137 Amnioexcel, amnioexcel plus or biodexcel, per square centimeter Amnioexcel biodexcel 1sq cmQ5101 Injection, filgrastim-sndz, biosimilar, (zarxio), 1 microgram Injection, zarxio ZA Novartis/sandoz Novartis/sandoz ZB Pfizer/hospira Pfizer/hospira ZC Merck/samsung bioepis Merck/samsung bioepisC9014 Injection, cerliponase alfa, 1 mg Injection, cerliponase alfaC9015 Injection, c-1 esterase inhibitor (human), haegarda, 10 units C-1 esterase, haegardaC9016 Injection, triptorelin extended release, 3.75 mg Inj, triptorelin ext relC9024 Injection, liposomal, 1 mg daunorubicin and 2.27 mg cytarabine Inj, daunorubicin-cytarabineC9028 Injection, inotuzumab ozogamicin, 0.1 mg Inj. inotuzumab ozogamicinC9029 Injection, guselkumab, 1 mg Injection, guselkumabC9030 Injection, copanlisib, 1 mg Inj copanlisibC9031 Lutetium lu 177, dotatate, therapeutic, 1 mci Lutetium lu 177 dotatate, txC9032 Injection, voretigene neparvovec-rzyl, 1 billion vector genome Voretigene neparvovec-rzylC9033 Injection, fosnetupitant 235 mg and palonosetron 0.25 mg Inj, akynzeo
C9275Injection, hexaminolevulinate hydrochloride, 100 mg, per study dose Hexaminolevulinate hcl
C9463 Injection, aprepitant, 1 mg Injection, aprepitantC9464 Injection, rolapitant, 0.5 mg Injection, rolapitant
C9465Hyaluronan or derivative, durolane, for intra-articular injection, per dose Injection, durolane
C9466 Injection, benralizumab, 1 mg Injection, benralizumabC9467 Injection, rituximab and hyaluronidase, 10 mg Inj rituximab hyaluronidase
C9468Injection, factor ix (antihemophilic factor, recombinant), glycopegylated, rebinyn, 1 i.u. Inj, factor ix, rebinyn
C9469Injection, triamcinolone acetonide, preservative-free, extended-release, microsphere formulation, 1 mg Inj triamcinolone acetonide
C9492 Injection, durvalumab, 10 mg Injection, durvalumabC9493 Injection, edaravone, 1 mg Injection, edaravoneC9497 Loxapine, inhalation powder, 10 mg Loxapine, inhalation powderJ0833 Injection, cosyntropin, not otherwise specified, 0.25 mg Cosyntropin injection nosJ9310 Injection, rituximab, 100 mg Rituximab injection
Q2040
Tisagenlecleucel, up to 250 million car-positive viable t cells, including leukapheresis and dose preparation procedures, per infusion Tisagenlecleucel car-pos t
Q5102 Injection, infliximab, biosimilar, 10 mg Inj., infliximab biosimilar
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6565
PartC—MedicareAdvantageChangeforThisYear• PerletterfromSeemaVerma,CMSisherebyrescindingourSeptember17,2012HPMSmemo“ProhibitiononImposingMandatoryStepTherapyforAccesstoPartBDrugsandServices,”andissuingnewguidancethatrecognizesMedicareAdvantage(MA)plansmayusesteptherapyforPartBdrugs,beginningJanuary1,2019,aspartofapatient-centeredcarecoordinationprogram.• Finally,MAplanswereinstructedtoensurethatnewsteptherapyrequirementsdonotdisruptongoingPartBdrugtherapiesforenrollees.SteptherapymayonlybeappliedtonewprescriptionsoradministrationsofPartBdrugsforenrolleesthatarenotactivelyreceivingtheaffectedmedication.Also,PartDtransitionrequirementswillcontinuetoapplytoPartDdrugsthataresubjecttosteptherapywherethefirst“step”isaPartBdrug.
https://www.cms.gov/Medicare/Health-Plans/HealthPlansGenInfo/Downloads/MA_Step_Therapy_HPMS_Memo_8_7_2018.pdf
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PartC—RiskAdjustmentProposedfor2020• CMSproposestoupdatetheHCCRiskAdjustmentModeltoincludeapaymentvariablerelatedtothenumberofconditionsthatanindividualbeneficiaryisdiagnosedwith.CMSseekscommentsregardingwhichoftwopotentialversionsoftheupdatedmodeltoimplementfor2020payments.• Version1:Currently,theweightofanHCCdominatestheadjustment.Anewriskadjustmentcalledthe"PaymentConditionCount"or"PCC"model,itincludesfactorsthattakeintoaccountthenumberofconditionseachbeneficiaryhas.IntheestablishedCMS-HCCmodel,thepredictedcostforahierarchicalconditioncategory("HCC")isnotimpactedbythepresenceofotherconditionsunlessthatspecificHCCispartofadiseaseinteraction.ThePCCmodelwouldincludeaseparatefactorforthecountofconditions,regardlessofwhatthoseconditionsmaybe,andasthenumberofconditionsincreases,anadjustmentwouldbemadetothetotalpredictedcost(i.e.,theriskscore);
• ORVersion2:ThisversionisexactlythesameasthePCCmodel,butitincludesHCCsforpressureulcersanddementiathatarenotinthecurrentriskadjustmentmodel--notabiggieforcancerclinicsandpractices.
• For2020,CMSproposesphasinginthenewmodelwithablendof50%oftheriskadjustmentmodelfirstusedforpaymentin2017and50%ofthenewmodelmodifiedorchangedfromtheproposal.
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PartC—SupplementalBenefitsProposed2020• TheDraftCY2020CallLetterproposestogiveMAplansflexibilitytoprovidecertainenrolleeswithabroaderrangeof
supplementalbenefits.• Traditionally,MAplanshaveonlybeenallowedtooffer"primarilyhealthrelated"supplementalbenefitsandmust
providethemtoallenrollees.• But,beginningin2019,CMSallowedMAplanstooffertargetedsupplementalbenefitsforspecificenrollee
populationsbasedonhealthstatusordiseasestate,aslongasthesupplementalbenefitsareoffereduniformlytothatgroup.YoumayhaveseentheSilverSneakerspushbysomeMedicareAdvantageplans.
• DuetopassageofTheBipartisanBudgetAct,CMSwillallowMAplans,beginningin2020,• tooffernon-primarilyhealthrelatedsupplementalbenefitstochronicallyillenrollees(e.g.,transportationfornon-
medicalneeds,home-deliveredmealsbeyondthecurrentallowablelimitedbasis,food,andproduce).• ThislawalsopermitsCMStowaiveuniformityrequirementsforchronicallyillenrolleesunderthenewprovision,
allowingMAplanstomodifysupplementalbenefitsbasedontheindividualenrollee'sspecificmedicalconditionandneeds.
• WillthisencouragemoreMAparticipation(Nowat36+%)
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PartC—Value-BasedInsuranceDesign(VBID)Proposed2020• InadditiontotheAdvanceNoticeandCallLetter,CMSrecentlyissueddocumentationregardinginnovationsthatCMMI(alsoinchargeoftheOncologyCareModel)planstotestthroughtheValue-BasedinsuranceDesign(VBID)modelfor2020.• CMSbeganusingtheVBIDmodelin2017totesttheimpactofprovidingMAplanswiththeabilitytooffer"reducedcostsharing"(MAplanshadthecost-sharingfordrugsin2018,accordingtoourdatabase)oradditionalsupplementalbenefitstoenrolleeswithspecificchronicconditions.
• Untilnow,theVBIDmodelhasonlybeentestedinselectstates.However,beginningin2020,MAplansinall50statesandinU.S.territoriesareeligibletoapplyfortheinnovationsbeingtestedthroughtheVBIDmodel.VBIDgivesMAplanstheabilitytofurthertailorbenefitdesigntowardsenrolleesbasedonchronicconditionsandsocioeconomiccharacteristics,suchaseligibilityforLowincomeSubsidypaymentsordual-eligibility.
• Additionally,theVBIDmodelfor2020willallowparticipatingMAplanstoproposeusingtelehealthservicesinsteadofin-personvisits.
• ParticipatingMAplanswillalsoberequiredtoofferenrolleesimprovedandtimelyaccesstoWellnessandHealthCarePlanning(WHP),includingadvancecareplanning.CMMIisacceptingapplicationstoparticipateinthe2020VBIDModelthroughMarch1,2019.
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PartD:RiskSharingProposal• AnewPartDModelwillallowfor(1)enhancedrisksharingbetweenPartDplansandCMS,and(2)thecreationofnewflexibilitiesandincentivesforplans,providersandbeneficiariestochooselowercostdrugs.BothstandalonePartDplansandMA-PartD(MA-PD)plansmayparticipateinthenewmodel.• CATASTROPHICRISK:PlansthatparticipateinthePartDModelwillassumegreaterriskinthecatastrophicphaseofPartDthantraditionalPartDplans.CMSwillcalculatethesharedsavings/lossesowedtoorbytheplanforagivencontractyearbyretrospectivelyestablishingaspendingtargetbenchmark.• CMSwillsetthebenchmarkattheamountofthefederalreinsurancesubsidy(80
percentofthePartDcatastrophicphasecostsafterrebate)thatCMSprojectsPartDplanswouldreceiveiftheywerenotparticipatinginthemodel.
• Planswithfederalreinsurancesubsidyspendingthatislowerthanthebenchmarkwillreceiveperformance-basedpaymentsthatarebasedonthetotalamountofsavings;planswithfederalreinsurancespendingthatishigherthanthebenchmarkwillowe10percentofthedifferencebacktoCMS.CMSwillcalculatesavingsorlossesattheparentorganizationlevel.
• PATIENTTOOLS:CMSalsomayallowtoolsforbeneficiaryuse,includingaPartDRewardsandIncentivesprogram,thatwillhelpbeneficiariesunderstandtheiroptions(forexample,genericorbiosimilarversusbrandnameoptionsthatareclinicallyequivalent)andout-of-pocketcosts,andhelpthembecomemoreactiveandengagedconsumers.Inaddition,planswillbeabletoproposedrugutilizationmanagementtechniquesaimedatchangingpatientchoicebehaviorforlowercostdrugs,assumingequalefficacy.
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PartD:Auto-shipProposed2020• TheDraftCY2020CallLetterwouldallowmailorderpharmaciestoauto-shiprefillstomembersundercertainconditions.Sincethe2014contractyear,CMShasrequiredPartDplansponsors(otherthannon- employergroupwaiverplans(EGWPs))toobtainpatientconsentpriortoshippingEACHrefillprescription.CMSproposesthat,forthe2020contractyear,PartDplansponsorswouldbepermittedtoauto-shiprefillsofdrugsthatamemberhasbeenonforatleastfourconsecutivemonths.TheDraftCY2020CallLetteroutlinesCMS'sexpectationsregardinganyauto-shipprogram,includingthefollowing:
• Beneficiarieswouldneedtoconfirmtheirenrollmentintheauto-shipprogramatleastannually.• Plansponsorswouldberequiredtosendtworeminderstothebeneficiarywellinadvanceofshipment(e.g.,
25and10daysprior).Thereminderscouldbebyphone,email,text,directmailingorother'comparablemeans'basedonpatientpreference.
• Memberswouldbepermittedtochoosetoparticipatefornone,allorsomeoftheirmedications.• Plansponsorswouldberequiredtorefundanyrefillsthatthebeneficiaryreportsasunneededorunwanted.
• Yikes!Whataboutthewaste?
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PartD:Sub-capitationProposed2020
• Intheirproposal,CMSaskedforcommentson"thebarriers,feasibility,andbenefits/drawbacks"ofincludingthecostofPartBandDdrugsinMAplans'riskarrangementswithnon-pharmacyproviders(e.g.,physiciangroupsoraccountablecareorganizations)inarequestforinformationsetoutintheDraftCY2020CallLetter.• CMSmaybeinterestedinestablishingtheadditionofthesePartBandPartDprescriptiondrugcostsinproviderriskarrangements,based,atleastinpart,onthestatutoryprohibitiononPartDplansponsorsrequiringpharmaciestotakeoninsurancerisk(inotherwords,thereisaprohibitiononsub- capitation).
• Bygivingnon-pharmacyprovidersafinancialincentivetomanageprescriptiondrugcosts,includingphysician-administereddrugs,CMShopesthatMAplansandPartDplansponsorswillbeableto"drivedownthecost"ofsuchdrugs.Thiscouldbeprettybad,ifpopularPartDplanspressurepracticesorhospitalstosub-capitateforPartBandPartDdrugs.
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7
WhatisRiskAdjustment?
•MedicareAdvantageadjuststheirmonthlypercapitapaymentstoHealthPlanstotakeintoaccounttherelativehealthoftheirmembers;“RiskAdjustment.”• HealthPlansreceivelesspaymentforhealthiermembers/patientsandmoreforsickermembers.• Therelativehealthor“riskadjustmentfactor”isbasedondiagnoses(codeddata)submittedbytheHealthPlanintheprioryear.• The“risk”scorecomesfromtheweight(assignedvalue)oftheHierarchicalConditionCategories(HCC)
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Cancer1)MetastasisCancer&Acute
Leukemia2)Lung,UpperDigestive
Tract,&OtherSevereCancers
3)Lymphatic,Head&Neck,Brain,&OtherCancers&Tumors
4)Breast,Prostate,Colorectal&OtherCancers&Tumors
Diabetes1)Diabetesw/RenalorPeripheralCirculatoryManifestation
2)Diabetesw/NeurologicorOtherSpecifiedManifestation
3)Diabetesw/AcuteComplications
4)Diabetesw/OphthalmologicorUnspecifiedManifestations
5)Diabetesw/oComplications
VascularDisease1)VascularDisease
w/Complications2)VascularDisease3)ChronicUlcerof
Skin,Exceptpressure(decubitus)
KidneyDisease1)DialysisStatus2)RenalFailure3)Nephritis
CMSModelCategoriesandHierarchies(HCCs)— examples
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COMPARISONOFHHSANDCMSMODELS
CMS Model HHS Model Implications
Attributes Age,gender,medicalconditions codedusingICD-10-CM
Age,gender,medicalconditionsandfinancialstatusforthosewhoqualifyforcostsharingreductions.Themodel alsoincludesdemographicattributesandproductinformation
Commercialriskadjustmentrequiresadditionaldatacapturefor demographics
DxCode Capture Medicalconditionshavetobetreated/addressedanddocumentedannuallyorneedtospecifythatthemembernolongerhasthe conditions
Chronicconditionsnotdocumentedannuallyarenotcapturedinrisk scores
Acceptable Codes Conditionsdocumentedduringface-to-faceencounterwithacceptedprovider types
Same,thereforeeasierinestablishingprovider practices
Acceptable Encounters Professional,inpatientand outpatient Same,thereforeeasierinestablishingprovider practices
Historical Conditions Codedandreportedconditionstransferwithmember
Nomember-leveldatatransferredbetween plans
Forcommercialriskadjustment,allconditionsneedtobedocumentedannuallyandwhenplan changes
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WHYISRISKADJUSTMENT DONE?• Riskadjustmentscores(alsoknownastheRiskAdjustmentFactororRAF)
arehigherforapatientwithgreaterdiseaseburden,lowerforahealthierpatient.
• EachpatienthasanRAFscorethatincludesbaselinedemographicelements(age/sexanddualeligibilitystatus)aswellasincrementalincreasesbasedonHCCdiagnosessubmittedonclaimsfromfacetofaceencounterswithqualifiedpractitionersduringthecalendaryear.
• HCCcodingisprospectiveinnature.TheworkdonethisyearsetstheRAFandsubsequentfundingfornext year.
• Diagnosiscodes,alongwithdemographics, reportedonyourclaimsdetermineapatient’sdiseaseburdenandriskscore.
• Chronicconditionsmustbereportedonceperyear.EachJanuary1,theRAwillreset,meaningyoumustreport.AllofyourMedicarepatientsareconsideredcompletelyhealthyuntildiagnosiscodesarereportedonclaims.
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RiskAdjustment&HCCDocumentationBasics
• ‘Activetreatment’status:Conditionsthatarepresentandunresolvedorunlikelytoresolveneedtobedocumentedatleastannually. CMSconsiderstheconditionresolvedifnotevaluatedandcodedatleastonce/calendaryear.
• ‘Forever’codes– conditionsthatdonotgoawayandpatientsareexpectedtohaveforever,e.g.,amputation,transplant,alcoholisminremission,CHF(compensated)
• Maybe‘forever’codesinclude:ostomy,cirrhosis,diabetes,hepatitis,,paraplegia/quadriplegia(bespecific)
• “Historyof”or“Pastconditions”• Historyofcancerisused,ifnotinactivetreatmentanddoesnothaveactivedisease.
Canceronlong-termtherapyisactivecancerwhenthetherapyisnotprophylactic• HistoryofstrokeorCVA– documentdeficitsandhistoryofincident(e.g.,hemiplegia
secondarytoCVA)
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DIAGNOSISCODING Tips
• Documentationmustshowthatconditionwas:• Monitored– Signs,symptoms,diseaseprogression,disease regression• Evaluated– Testresults,medicationeffectiveness,responseto treatment• Assessed/Addressed– Orderingtests,discussion,reviewrecords,counseling
• Treated– Medications,therapies,other modalities
• Adiagnosiscodemayonlybereportedifitisexplicitlyrecorded inthemedical record:• Nocodingfrom superbills orlabresultsbythemselves• Treatmentisprimafasciaevidenceofadiagnosis– ifyouaretreating,ittherefore exists
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COMMONCODINGERRORS
• Electronicmedicalrecord(EMR)wasunauthenticated(notelectronicallysigned).
• HighestdegreeofspecificitywasnotassignedthemostpreciseICD-10tofullyexplaintonarrativedescriptionofthesymptomordiagnosisinthemedical chart.
• Manifestationsnotrecorded—particularlyindiabetes…• Documentationdoesnotindicatethediagnosisisbeing
monitored,evaluated,assessed/addressed,ortreated (MEAT).• Chronicconditions,suchashepatitisorrenalinsufficiency,arenot
documentedas chronic.• Chronicconditionsorstatuscodesaren’tdocumentedinthemedical
recordatleastonce per year.• Assumptionthatotherpeople’scodingappliestoyou.
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8282
CapturetheConditionsAnnually!
•EachpatientisTOTALLYHEALTHY onJanuary1EVERYYEAR
•Amputationsgrowback!•COPDpatientshavehealthylungs!•Metastasesgoawaywithoutdirecttreatment!•Allkidneysfunctionflawlessly!•Colostomypatientshaveaperfectcolon!•Getthepicture?IFYOUDON’TDOCUMENTANDCODETHECONDITION,ITDIDN’THAPPEN!
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8383
ToDo’sfor2019
• Areyoubillingforallservicesthatcanbereimbursedrightnow???
• SendanNDCforallpayers.Makesureit’sinthe5-4-2formatnomatterwhattheManufacturerwebsitesays.
• Fortheyourmajorpayers,knowwhenclaimssubmissionexpires.Youareleavingmoneyonthetable!!
• CheckouttheMedicallyUnlikelyEditseveryquarterathttps://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/MUE.html
• Trumpcaretemporaryplanschangethewayinsuranceisverified.Thingsyounowneedtoknow:• Ceilings/CAPS:Drugs,Annual,Lifetime• ObamacarePremiumChanges• Benefits—All10?
• MonitorMedicareAdvantagedrugapprovalchangesforStepTherapy.
• ReadmoreaboutHCCshere:http://bok.ahima.org/doc?oid=302516#.XIguPZNKh-U
• EnsureyouknowEACHTIMEthepatientcomesin—changeofemployment,insurance,premiumpayment.
• WatchforchangesinDrugReimbursement.ParticipateintheStruggle.
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87
onPointfocalPoint®Data• Demographics
• 2200+physicians• 170practices• 2.573millionclaimsin2018• 392,000patients• 439Commercialplans
• Data• Drugclaimsonlyrealtime• Allothertransactionsbyreport• AlldataisforINSURANCEONLY
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88
CollectionRatesfromAllowables
Percentage Category88.10% Overall Collection
Percentage
89.09% Drug Collection Percentage
91.22% RadOnc Collection Percentage
67.66% Imaging Collection Percentage
80.55% E/M Collection Percentage
Collection Percentage
NetCollection=Netofdenials,patientportions,anddiscounts
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90
DenialPercentage
Denial PercentCategory
15.85% Overall Denial Percentage
11.17% RadOnc Denial Percentage
18.86% Imaging Denial Percentage
11.67% E/M Denial Percentage
8.86%Drug Denial Percentage
Denial Percentage
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91
DaysToPay
DaystoPay Category32 OverallDaysto
Pay33 RadOncDaysto
Pay32 ImagingDaysto
Pay29 E/MDaystoPay50 DrugDaystoPay
WithOutliers*:*Withoutoutliersitisabout31days
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9393
Quality Payment Program: Merit-based IncentivePaymentSystem(MIPS)Year3(2019)Final
MIPSeligible cliniciansinclude:• Physicians• Physician Assistants• Nurse Practitioners• ClinicalNurse Specialists• CertifiedRegisterNurseAnesthetists
• Groupsofsuch clinicians
MIPSEligibleClinician Types:
Year2 (2018) Final Year3(2019) Final
MIPSeligibleclinicians include:• Same fivecliniciantypesfromYear2 (2018)
AND:• Clinical Psychologists• Physical Therapists• Occupational Therapists• Speech-Language Pathologists• Audiologists• RegisteredDieticiansorNutritionProfessionals 19
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9494
QPP:MIPSYear3(2019)FinalLow-VolumeThreshold Determinations:
1. Addedathirdelement– NumberofServices– tothelow-volumethresholddetermination criteria
• Thefinalizedcriteria include:
• Dollaramount- $90,000incoveredprofessionalservicesunderthePhysicianFeeSchedule(PFS)
• Numberofbeneficiaries– 200MedicarePartBbeneficiaries
• Numberofservices(New)– 200coveredprofessionalservicesunderthe PFS
2. Addedanopt-inoptionforYear 3
• IfyouareaMIPSeligibleclinicianandmeetorexceedatleastone,butnotall,ofthelow-volumethresholdcriteria,youmay opt-into MIPS
• Ifyouopt-in,you’llbesubjecttotheMIPSperformancerequirements,MIPSpaymentadjustment,etc.
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9595
QPP:MIPSYear3(2019)Final
PerformanceCategoryWeights:
Performance CategoryPerformanceCategoryWeights
Year1 (2017) Year2 (2018) Year3(2019)– Final
Quality
60% 50% 45%
Cost
0% 10% 15%
Improvement Activities
15% 15% 15%
PromotingInteroperability
25% 25% 25%
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9696
QPP:MIPSYear3(2019)Final
PerformanceCategories– AdditionalHigh-LevelChanges:Quality:RemovedcertainmeasuresasapartoftheMeaningfulMeasuresInitiativeandshiftedthe small practicebonus(worth6points)fromthefinalscorecalculationintothisperformance category
Cost: Added8newepisode measures
Facility-basedqualityandcostmeasures:Clinicianswhoarehospital-basedcanusetheirhospital’sperformanceundertheHospitalValue-BasedPurchasing(VBP)ProgramfortheMIPSqualityandcostperformancecategories
ImprovementActivities:RefinementsmadetotheImprovementActivities inventory
PromotingInteroperability:Overhauledthecategorytosimplify,focusoninteroperability,align clinicianpolicieswithhospitalpolicies,reducemeasures,andchangescoringtobefocusedon performance
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9797
QPP:MIPSYear3(2019)FinalSubmittingData:
Collectiontype- asetofqualitymeasureswithcomparablespecificationsanddatacompletenesscriteria,asapplicable,including,butnotlimitedto:electronicclinicalqualitymeasures(eCQMs);MIPSClinicalQualityMeasures*(MIPSCQMs);QualifiedClinicalDataRegistry(QCDR)measures;MedicarePartBclaimsmeasures;CMSWebInterfacemeasures;theCAHPSforMIPSsurvey;andadministrativeclaims measures
Submissiontype- themechanismbywhichasubmittertypesubmitsdatatoCMS,including:direct,loginandupload,log inandattest,MedicarePartBclaims,andtheCMSWeb Interface
• TheMedicarePartBclaimssubmissiontypeisforindividualcliniciansorgroupsinsmallpracticesonly tocontinueprovidingreporting flexibility
Submittertype- theMIPSeligibleclinician,group,virtualgroup,orthirdpartyintermediaryactingonbehalfofaMIPSeligibleclinician,group,orvirtualgroup,asapplicable,thatsubmitsdataonmeasuresandactivitiesunder MIPS
*ThetermMIPSCQM replaces whatwasformerlyreferredtoas“registrymeasures”sincecliniciansthatdon’tusearegistry maysubmitdataonthese measures
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9898
QPP:MIPSYear3(2019)Final
PerformanceThresholdandPayment Adjustment:
*Paymentadjustment(andexceptionalperformerbonus)isbasedoncomparingfinalscoretoperformancethresholdandadditionalperformancethresholdforexceptionalperformance.Toensurebudgetneutrality,positiveMIPSpaymentadjustmentfactorsarelikelytobeincreasedordecreasedbyanamountcalleda“scalingfactor.”TheamountofthescalingfactordependsonthedistributionoffinalscoresacrossallMIPSeligible clinicians.
Performance Period Performance ThresholdExceptionalPerformance
BonusPayment Adjustment*
Year1 (2017) 3 points 70points Upto +4%
Year2 (2018) 15 points 70 points Upto +5%
Year3(2019)- Final 30points 75points Upto +7%
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9999
QualityPaymentProgram:AdvancedAlternativePaymentModels(APMs)Year3(2019)Final
General:
• IncreasedtheAdvancedAPMCEHRTthresholdsothatanAdvancedAPMmustrequirethatatleast75% ofeligiblecliniciansineachAPMEntityuse CEHRT
• Extendedthe8%revenue-basednominalamountstandardforAdvancedAPMsthroughperformanceyear2024
• StreamlinedthedefinitionofaMIPScomparable measure
MIPSAPMsandtheAPMScoring Standard:
• ReorderedthewordingofthecriteriontostatethattheAPM“basespaymentonqualitymeasures andcost/utilization”toclarifythatthecost/utilizationpartofthepolicyisbroaderthanspecificallyrequiring theuseofacost/utilization measure
• UpdatedtheMIPSAPMmeasuresetsthatapplyforpurposesoftheAPMscoring standard
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100100
QPP:AdvancedAPMsYear3(2019)Final
All-PayerCombination Option:• IncreasedflexibilityfortheAll-PayerCombinationOptionandOtherPayerAdvanced
APMsfor non-MedicarepayerstoparticipateintheQualityPayment Program
• Established a multi-year determination process where payers and eligible clinicianscan provide information on the length of the agreement as part of their initial OtherPayer Advanced APM submission, and have any resulting determination be effectivefor the duration of the agreement
• Allowing QP determinations at the TIN level in addition to the APM Entity andindividual eligible clinician levels in certain instances when all eligible clinicians whohave reassigned their billing rights to the TIN are included in a single APM Entity
• Permittingallpayertypestobeincludedinthe2019PayerInitiatedOtherPayerAdvancedAPMdeterminationprocessforthe2020QPPerformance Period
• IncreasedtheCEHRTusecriterionthresholdsothatinordertoqualityasanOtherPayerAdvancedAPMasofJanuary1,2020,CEHRTmustbeusedbyatleast75%ofeligiblecliniciansintheotherpayer arrangement
• Maintainedtherevenue-basednominalamountstandardforOtherPayerAdvancedAPMsat8% through performanceperiod 2024