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The Regulatory Road Ahead: What to Expect in 2016 and Beyond
Q1 Regulatory Update – 02/25/16
What we’ll cover: • Current Healthcare Market Overview and Trends • PQRS Update • Merit-based Incentive Payment System • Therapy Cap • Innovative and Alternative Payment Models • Additional Regulatory Updates • Resources
About Our Company
Our goal at SourceMed is to be the leading provider of innovative next generation software and services solutions for the outpatient
continuum of care, enabling our clients to fulfill their mission of delivering high quality, cost-effective patient care.
About Our Speaker
David McMullan, PT
is the Chief Therapy Officer for SourceMed. David has over 20 years of outpatient rehabilitation healthcare experience in both private practice and hospital settings.
The Current Healthcare Market: Overview and Trends
Current Healthcare Overview and Trends
Value-Based
Payment
MACRA
Technology Population Health
Alternative Payment Models
Current Healthcare Overview and Trends
• Interoperability
• Data Sharing / Security
• Virtual Healthcare
• Patient Engagement: • Patient Reported Outcomes
• Wearable Devices
• Timely Communication
Technology
Current Healthcare Overview and Trends
Medicare Access and CHIP Reauthorization Act
of 2015 (MACRA)
• H.R. 2 signed into law April 16, 2015
• Permanent repeal of Sustainable Growth Rate
(SGR)
• Annual payment updates: o 0.5% 2016‐2019
o 0.0% 2020‐2025
o 2026 and beyond 0.75% for eligible Alternative Payment
Model (APM) participants, 0.25% for all others
MACRA
Current Healthcare Overview and Trends
Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) • Creation of Merit‐based Incentive Payment System (MIPS)
• Current penalties under the Physician Quality Reporting System (PQRS), Electronic Health
Records/Meaningful Use (MU), and the value‐based payment modifier (VBM) will end at the
close of 2018.
• MIPS begins in 2019. Bonuses are on a sliding scale penalties begin at up to 4
percent in 2019
• Up to 5 percent in 2020;
• Up to 7 percent in 2021; and
• Up to 9 percent in 2022 and beyond.
Current Healthcare Overview and Trends
Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)
• Alternative Payment Models (APM)
o Will receive 5% bonus payments if participating in an approved APM from 2019
to 2024
o Requires an increasing percentage of patients in APMs each year
Current Healthcare Overview and Trends
HHS Transition Timelines:
• Alternative Payment Models
o 30% of payments tied to alternative payment models
by 2016; 50% by the end of 2018
• Linking Payment to Outcomes
o 85% of fee for service payments tied to outcome
measures by end of 2016; 90% by end of 2018
The Health Care Transformation Task Force
• 75% of payments into value‐based models by
January 2020
Value-Based
Payment
Current Healthcare Overview and Trends
Fee for Service • Volume of Services • No tie to outcomes
Pay for Reporting * Requires data submission to avoid penalty * No benchmarking
Value-Based
Payment * Benchmarking outcomes, quality measures * +/neutral/‐ payment adjustment
Current Healthcare Overview and Trends
• Not fee‐for‐service
• Accountable care organizations
• Bundling of services
• Comprehensive Care Joint
Replacement Model
Alternative Payment Models
Current Healthcare Overview and Trends
Population at Large
•Institute of Medicine Vital Signs, Core Metrics for Health and Health Care Progress • Includes measures for well being,
obesity, preventative services, access, patient safety, evidence‐based care, care match with patient goals, etc.
• http://iom.nationalacademies.org/Reports/2015/Vital‐Signs‐Core‐Metrics.aspx
Disease/Condition Specific
•Increasing use of patient registries that allow for the management of patient populations
•Bundling of services for patient populations
Current Healthcare Overview and Trends
TRIPLE AIM: • Better Health • Better Care • Lower Cost
Institute for Healthcare Improvement Link
PQRS Update
• Notification letters sent out in November 2015 • Reporting performance for 2014 impacts 2016 payment • -2% penalty for non-compliance or unsuccessful reporting • The culprit Measure #130 – Documentation of Current
Medications o 97001/97002 o 97003/97004 o 97110 o 97140 o 97532
CMS 2016 PQRS Payment Adjustment Toolkit: : CMS 2016 PQRS Payment Adjustment Toolkit
Update on PQRS 2014 Reporting
Physician Fee Schedule – PQRS Changes for 2016
Program Detail Changes Successful reporting requirements
• Same as 2015: Reporting of 9 measures (or 1‐8 as applicable) on 50% of eligible patients will be needed to avoid the ‐2.0% penalty
Available measures • No new measures and no measures removed
Specific measure changes
• No coding changes to report • Additional clarifying details added to some measures • Please review all measures that you are reporting
Reporting Mechanisms
• No changes
PQRS 2016 Reporting
• PQRS in 2016 In 2016, eligible providers who bill under the physician fee schedule
must report successfully under PQRS to avoid a ‐2.0% reduction in their 2018 fee schedule payment. PTs can report via claims or registry Rehab agencies, outpatient hospitals, SNFs Part B unable to participate in PQRS; use UB‐92
(UB‐04) or 837I for billing to intermediary No place on claim form for individual NPI
To avoid the penalty in 2018: In 2016, report at least 9 measures OR, if less than 9 measures covering apply to the
eligible professional, report 1—8 measures, AND report each measure for at least 50 percent of the Medicare patients to which the measure applies
Regulatory and Compliance Challenges for 2016
PQRS 2016 Reporting
2016 PQRS Measures for Physical Therapists
Measure # Measure Description 128 Preventive Care and Screening: BMI Screening and Follow-up 130 Documentation and Verification of Current Medications in the Medical
Record 131 Pain Assessment Prior to Initiation of Patient Treatment 154 Falls: Risk Assessment 155 Falls: Plan of Care 182 Functional Outcome Assessment
Table Note: Select all six 2016 codes for PT claims based reporting. Be sure to read 2016 measure specifications for each code to ensure compliance in reporting.
PQRS 2016 Reporting
2016 PQRS Reporting Participation
PQRS 2016 Reporting Pa
rtic
ipat
ion
in P
QRS
Repo
rting
in 2
016?
YES, I want to avoid the -2%
penalty in 2018
Report via claims
Report via registry
Report all available individual measures
(128, 130, 131, 154, 155, 182)
Select 9 individual measures (or if less
available 1-8)
• Claims Based Reporting for 2016 PQRS Data: Evaluate Patient:
Perform PQRS measures Document clinical findings and related care
Submit Claim: Include all PQRS codes $0.01 charge No GP/KX modifiers
Review Feedback Report: Access reports from Quality Net throughout the year Quality Net Portal Correct any PQRS issues.
• Registry Based Reporting for 2016 PQRS Data: 2015 PQRS Qualified Registries 2016 PQRS Registry Reporting Made Simple
Recommended PQRS Registry – FOTO
Reporting Options for 2016 PQRS Data
PQRS 2016 Reporting
Failing to include PQRS data on an original claim
Placing invalid modifiers on the PQRS codes including GP or KX
Failing to meet 50% reporting rate for all selected measures
• Make sure PQRS codes are included on all eligible initial claims
• Claims cannot be resubmitted for the sole purpose of adding a PQRS code
• Placing a GP or KX modifier will cause the PQRS to reject form the system
• You cannot resubmit the claim to correct PQRS code errors
• Consistently report PQRS measures on all eligible patients throughout the year
• Do not select different measures for each patient; report selected measures on all patients
• Report on all eligible visits including 97002 and 97532
PQRS: Errors to Avoid
PQRS 2016 Reporting
PQRS Functional Limitation Reporting Quality Assurance Outcomes
Voluntary Required/Mandatory
Certain visits are eligible for PQRS reporting based on specific criteria: • Age • Other procedure performed • Additional factors – Diagnosis, other PQRS
measures or results
Required/Mandatory reporting on certain visits: • Evaluation and Re-Evaluation • Known Discharge Visit • Change in Functional Status • Every 10 visits
Financial penalty for non-participation or unsuccessful reporting
Claim rejection without reporting
PQRS Versus FLR
The only thing these two have in common is the both have CPT codes that start with the letter “G”
PQRS 2016 Reporting
PQRS Merit-based Incentive Payment System (MIPS) • Report on a specific number of quality
measures for 50% or more of all eligible Medicare patients
• 4 performance categories: Quality measures (PQRS) 45% Resource use 15% Clinical improvement activities 15% Meaningful use 25%
• Pay for reporting; if you meet reporting requirements no penalty
• Providers will earn a performance score (0‐100) and will be incentivized/ penalized based on performance
• Current measures are not always meaningful to practice
• Opportunity to develop measures meaningful to practice
• 2016: report on 6 measures for 50% or more for all visits in which a 97001/ 97002 is billed
• CMS will be outlining further details of MIPS over the course of 2016
PQRS Versus MIPS
PQRS 2016 Reporting
The current quality reporting programs under Medicare part B will be replaced with a new quality reporting program, the Merit-based Incentive Payment System (MIPS), in 2017 as
required by the Medicare Access and CHIP Reauthorization Act of 2015 legislation. MIPS will begin in 2017 for physicians and other practitioners, but will not include physical therapists. The Secretary has the discretion to add physical therapists to MIPS beginning in the 2019
reporting year (2021 payment adjustment year).
Calendar /Current Year (Data Year)
Year Incentive/Penalty Payment Applied
PQRS Incentive/ Penalty* (calculated by NPI/TIN)
Merit-based Incentive Payment System
(MIPS)
2017 2019 NA NA
2018 2020 NA NA
2019
2021
NA
3.0x to -7.0% CMS may add remaining EPs** (including PTs) to
program
Future of PQRS Reporting
Merit-Based Incentive Payment System (MIPS)
45% = Quality Measures • PQRS measures (there are indications that some will move to MIPS) • Process and outcomes measures (move toward outcomes) • All new measures must be published in peer reviewed journal or developed by QDCR
15% = Resource Use • Currently, PTs do not have any measures in this category
15% = Clinical Activities • Not yet outlined • Categories include: expanded practice access; population management, care coordination, beneficiary
engagement (Secretary required to specify activities)
25% = Meaningful Use • PTs would have the weight from this category redistributed to other categories
MIPS Detail
MIPS Timeline
2021 Report MIPS Data Subject to potential incentive or penalty based on reporting in
MIPS program in 2019 (3.0% to -7.0%)
2020 Report MIPS Data No Payment Adjustment
2019 Report MIPS data? (Secretary has ability to add PTs to
program in 2017) No Payment Adjustment
2018 No Reporting Subject to 2.0% penalty if you failed to report PQRS data
successfully in 2016
2017 No Reporting Subject to 2.0% penalty if you failed to report PQRS data
successfully in 2015
2016 Report PQRS Data Subject to 2.0% penalty if you failed to report PQRS data
successfully in 2014
Therapy Cap
• 2016 Therapy Cap = $1,960.00 o PT & SLP Combined Still o OT Med Learn Matters MM9448
• Based on Medicare Allowed Charges after MPPR has been applied and before the 1.6% government sequestration has been applied o Allowed Charges = $122.79
• Discounted Payment After MPPR = $111.40 (-9.28%) • After Sequestration = $109.61 (-10.78%)
• Medicare program pays 80% of allowed amount Medicare Limits on Therapy Services
2016 Therapy Cap
• Therapy cap exception process is in effect through December 31, 2017. • If a Medicare beneficiary has reached the therapy cap and requires
therapy services above the cap, providers will have to append the KX modifier to those CPT codes on the claim form
• The KX modifier will bypass edits in place and allow payment for services above the $1,960.00
• The decision on whether or not to append the KX modifier is that of the treating or supervising therapist
• Use of the KX modifier attests that the services provided require the unique skills of a therapist to provide or an assistant under the supervision of the therapist
• No special documentation is required • Clinicians may utilize the process for exception for any diagnosis or
condition for which they can justify services exceeding the cap.
Therapy Cap Exceptions Process
• Occurs when a Medicare beneficiary exceeds $3,700.00 in physical and speech therapy services combined or separate $3,700.00 for occupational therapy in a calendar year based on the allowed amount
• There is a new process for the manual medical review process that began July 2015
• CMS will determine which therapy services to review by considering certain factors:
– Providers with patterns of aberrant billing practices compared with their peers – Providers with a high claims denial percentage or who are less compliant with applicable Medicare
program requirements – Providers who are newly enrolled – Providers who treat certain types of medical conditions – Providers who are part of a group that includes another therapy provider identified by the above
factors
Manual Medical Review
Innovative and Alternative Payment Models
HHS measurable goals and timeline
Tying payment to alternative
payment models and pay for
performance
30% by the end of 2016 to APM
50% by the end of 2018 to APM
85% to quality by end of 2016 and
90% by 2018
Moving from Volume to Value
Current Quality Programs Under Medicare – PT Specific
Future Quality Programs
Comprehensive Care for Joint Replacement Model (CJR): The Comprehensive Care for Joint Replacement (CJR) model aims to support better and more efficient care for beneficiaries undergoing the most common inpatient surgeries for Medicare beneficiaries: hip and knee replacements (also called lower extremity joint replacements or LEJR). This model tests bundled payment and quality measurement for an episode of care associated with hip and knee replacements to encourage hospitals, physicians, and post-acute care providers to work together to improve the quality and coordination of care from the initial hospitalization through recovery. The proposed rule for the CJR model was published on July 9, 2015, with the comment period ending September 8, 2015. After reviewing nearly 400 comments from the public on the proposed rule, several major changes were made from the proposed rule, including changing the model start date to April 1, 2016. The final rule was placed on display on November 16, 2015 and can be viewed at the Federal Register Bundled Payments for Care Improvement (BPCI) Initiative: The Bundled Payments for Care Improvement (BPCI) initiative is comprised of four broadly defined models of care, which link payments for the multiple services beneficiaries receive during an episode of care. Under the initiative, organizations enter into payment arrangements that include financial and performance accountability for episodes of care. These models may lead to higher quality and more coordinated care at a lower cost to Medicare.. Over the course of the initiative, CMS will work with participating organizations to assess whether the models being tested result in improved patient care and lower costs to Medicare
Bundled Payment Initiatives
CMS has implemented the CJR model in 67 geographic areas, defined by metropolitan statistical areas (MSAs). MSAs are counties associated with a core
urban area that has a population of at least 50,000. Non-MSA counties (no urban core area or urban core area of less than 50,000 population) were not eligible for
selection. • Aims to support better and more efficient care for beneficiaries undergoing the most common
inpatient surgeries for Medicare beneficiaries • Applies to total hip and knee replacements • In 2014, more than 400,000 hip and knee replacements were performed • Hospitalization costs totaled more than $7 billion • Average Medicare expenditure for surgery, hospitalization, and recovery ranges from $16,500
to $33,000 across geographic areas
CJR Model
Metropolitan Statistical Areas Selected to Participate in CJR Model Akron, OH Greenville, NC Oklahoma City, OK Albuquerque, NM Harrisburg-Carlisle, PA Orlando-Kissimmee-Sanford, FL Asheville, NC Hot Springs, AR Pensacola-Ferry Pass-Brent, FL Athens-Clarke County, GA Indianapolis-Carmel-Anderson, IN Pittsburgh, PA Austin-Round Rock, TX Kansas City, MO-KS Port St. Lucie, FL Beaumont-Port Arthur, TX Killeen-Temple, TX Portland-Vancouver-Hillsboro, OR-WA Bismarck, ND Lincoln, NE Provo-Orem, UT Boulder, CO Los Angeles-Long Beach-Anaheim, CA Reading, PA Buffalo-Cheektowaga-Niagara Falls, NY Lubbock, TX Saginaw, MI Cape Girardeau, MO-IL Madison, WI San Francisco-Oakland-Hayward, CA Carson City, NV Memphis, TN-MS-AR Seattle-Tacoma-Bellevue, WA Charlotte-Concord-Gastonia, NC-SC Miami-Fort Lauderdale-West Palm Beach, FL Sebastian-Vero Beach, FL Cincinnati, OH-KY-IN Milwaukee-Waukesha-West Allis, WI South Bend-Mishawaka, IN-MI Columbia, MO Modesto, CA St. Louis, MO-IL Corpus Christi, TX Monroe, LA Staunton-Waynesboro, VA Decatur, IL Montgomery, AL Tampa-St. Petersburg-Clearwater, FL Denver-Aurora-Lakewood, CO Naples-Immokalee-Marco Island, FL Toledo, OH Dothan, AL Nashville-Davidson--Murfreesboro--Franklin, TN Topeka, KS Durham-Chapel Hill, NC New Haven-Milford, CT Tuscaloosa, AL Flint, MI New Orleans-Metairie, LA Tyler, TX Florence, SC New York-Newark-Jersey City, NY-NJ-PA Wichita, KS Gainesville, FL Norwich-New London, CT Gainesville, GA Ogden-Clearfield, UT
CJR Model
Comprehensive Care for Joint Replacement (CJR) model • CJR model start date to April 1, 2016. The final rule was placed on display
on November 16, 2015 and can be viewed at the Federal Register Federal Register CCJR Model for Acute Care Hospitals
• Required hospital program in selected areas • No change to hospital and professional payments • Hospital Financial Incentives:
o Complication Rates o Consumer Surveys o Cost for hospitalization plus care 90 days post D/C
CJR Model
APTA is planning to update their webpage with the following resources including: • Basic information about the model • Contracting considerations • Clinical practice guidelines, best practices • Functional tools http://www.apta.org/BundledModels/CJR/
CJR Model
Model Episode of Care Hospital Payment Professional Payment
1 Inpatient Stay Only Discounted PPS Fee for Service
2 Inpatient Stay + 90 Days Post Acute Care
Targeted Bundled Payment Rate Payment or recoupment based on all expenses
Fee for Service
3 90 Days Post Acute Care Targeted Bundled Payment Rate Payment or recoupment based on all expenses
Fee for Service
4 Inpatient Stay Only Single, predetermined bundled payment
Paid by hospital out of bundled payment
BPCI Homepage
Bundled Payments for Care Improvement (BPCI)
BPCI
Physical Therapy Classification & Payment System (PTCPS) • Formerly the “Alternative Payment System” • Renamed PTCPS & Refined by APTA Task Force • Submitted to AMA • Currently Under Consideration
New Payment Model
• October 2015: APTA and AOTA present their respective evaluation and reevaluation codes to the Health Care Professional Advisory Committee (HCPAC), a subgroup of the RUC that comprises non-physician providers. The HCPAC accepts the recommendations from both groups. Following the October meeting, the AMA RUC submits the HCPAC recommendations to CMS.
• July 2016: The CY 2017 Medicare Physician Fee Schedule Proposed Rule will be released by CMS, which will include the proposed values for the physical therapy and occupational therapy evaluation and reevaluation codes. APTA and AOTA will have 60 days to comment on the proposed rule. At this time, APTA will also launch a comprehensive educational campaign to prepare physical therapists for the implementation of the new evaluation and reevaluation codes.
• October-November 2016: The CY 2017 Medicare Physician Fee Schedule Final Rule will be released, containing the final values for the new physical therapy and occupational therapy evaluation and reevaluation codes. APTA's educational campaign will continue and will adjust as needed from initial efforts.
• January 1, 2017: Implementation of the new physical therapy and occupational therapy codes. The new codes become will active and current physical therapy and occupational therapy evaluation and reevaluation codes (97001, 97002, 97003, and 97004) will be deleted
New Payment Model - PTCPS
PTCPS
APTQI seeks unity, transparency among PT professionals The American Physical Therapy Association (APTA) is making decisions that affect your livelihood. Their proposed changes to the codes for physical therapy services could turn a difficult yet solvable challenge into a catastrophe. The recently-released pilot study on the proposed code set has proved its unreliability. The APTA should be responsible and stop advocating for changing these treatment codes. We believe any future modification of the treatment code proposal will require further testing and qualitative feedback. • 15,000 therapists strong • 50 State Coverage • 4,000 Clinics Represented • 3 million Patients Served Annually http://www.aptqi.com/default.aspx
New Payment Model - APTQI
“We know that CMS is phasing out Physician Quality Reporting System and phasing in a Merit-Based Incentive Payment System (MIPS). For now, non-physicians are not included in MIPS.” “We know that APTA, while working with the AMA work group, has again altered the PTCPS where the number of levels in the model has been substantially reduced. We know that APTA is keeping it confidential and not providing details.” “Both PTBA and APTQI know that payment reform affects every physical therapist (member of APTA or not). Both PTBA and APTQI believe all need to work together to create an adequate solution, all need to be transparent and all need to collaborate better.” There is no projected start date for any new payment model. http://www.ptballiance.org/
New Payment Model - PTBA
Additional Regulatory Updates
• Focus on outpatient physical therapy services provided by independent therapists who have a high utilization rate
• Determination of compliance with Medicare
• States that prior findings are that claims were not reasonable or were not properly documented or that the therapy services were not medically for outpatient physical therapy services
OIG Work Plan for 2016: OIG Work Plan for Fiscal Year 2016 Link
OIG 2016 Work Plan
Comparative Billing Reports • CMS Contractor eGlobal Tech • CMS Educational tools and not punitive carried out by eGlobal Tech • Comparison to peers across the country • Information is shared with MACs
• CBR201511: analysis for PT included the CPT codes 97001, 97035, 97110, 97112, 97140, 97530, G0283
Comparative Billing Reports Webinar Nov 2015 Link
Comparative Billing Reports
Resources
Resources PQRS: • CMS PQRS Home page: CMS PQRS Home Page Link • CMS – Medicare Payment Adjustment toolkit: Medicare Payment Adjustment Tool Link • APTA: http://www.apta.org/PQRS/ • Quality Net: Quality Net Link MIPS: • Quality Measurement Development Plan – DRAFT: CMS - Quality Initiatives Value-Based-
Programs MIPS and APMs Link Therapy Cap: • CMS MLN Matters MM9448 – Therapy Cap: MedLearn Matters MM9448 Therapy Cap 2016
Download Link • Medicare Cap Limits for Therapy Services: CMS Therapy Cap 2016 Limits Info Link • Manual Medicare Review: Manual Medicare Review of Therapy Claims Above Threshold Link
New Payment Model: • APTA: http://www.apta.org/PTCPS/Overview/ • APTQI: http://www.aptqi.com/default.aspx • PTBA: http://www.ptballiance.org/
Resources
OIG: • OIG Work Plan for 2016: OIG Work Plan for Fiscal Year 2016 Link • Section 220; 220.3: CMS Regulations-and-Guidance Manuals downloads link eGlobal Tech Comparative Billing Reports: Comparative Billing Reports Webinar Link Nov 2015 Bundled Payment Initiatives: • Comprehensive Care for Joint Replacement Model (CCJR): CMS -Innovation Initiatives - CJR Link • Bundled Payments for Care Improvement (BPCI) Initiative: CMS - Innovation Initiatives Bundled
Payments Care Improvement Initiative Link • APTA: http://www.apta.org/BundledModels/CJR/
