Quality Payment Program: The future of reimbursement

Quality Payment Program: The future of reimbursement Presented by Evan M. Gwilliam, DC MBA BS CPC CCPC NCICS CCCPC CPC-I MCS-P CPMA CMQP Executive Vice President 1 Dr. Evan Gwilliam Education Bachelor s of Science, Accounting - Brigham Young University Master s of Business Administration - Broadview University Doctor of Chiropractic, Valedictorian - Palmer College of Chiropractic Certifications Certified Professional Coder (CPC) - AAPC Certified Chiropractic Professional Coder (CCPC) - AAPC Qualified Chiropractic Coder (QCC) - ChiroCode Certified Professional Coder Instructor (CPC-I) - AAPC Medical Compliance Specialist Physician (MCS-P) - MCS Certified Professional Medical Auditor (CPMA) AAPC, NAMAS Certified ICD-10 Trainer AAPC Certified MIPS Healthcare Professional 4Med 2 1

https://mips.qvhsystems.com/mips/fac MACRA Medicare Access and CHIP Reauthorization Act of 2015 Ended the Sustainable Growth Rate (SGR) formula for determining Medicare payments for health care providers services. Makes a new framework for rewarding health care providers for giving better care, not more just more care. Combines our existing quality reporting programs (PQRS, Meaningful Use, and the Value Based Payment Modifier) into one new system 4 2

MACRA Medicare Access and CHIP Reauthorization Act of 2015 By 2018, 50% of payments should be made under the value-based model Two tracks: oadvanced Alternative Payment Models (APMs) omerit-based Incentive Payment System (MIPS) Reforms payments for about 600,000 clinicians in 2017 5 MIPS Exclusions Receive less than $30,000 per year in allowed charges from CMS OR Provide care to fewer than 100 Medicare beneficiaries per year OR Not one of these: OR In your first year participating in Medicare 6 3

Why should I participate? Threshold is likely to change Burden of reporting is not that high because you already do it anyway and your software should do most of the heavy lifting Your performance rating will become publicly available. Your reputation is on the line. 7 Performance period is 1/1/2017 through 12/31/2017 Start collecting data anytime between 1/1/2017 and 10/2/2017 Submit the data by 3/31/2018, and wait for feedback Payment adjustment (up, down, or unchanged) begins 1/1/2019 8 4

MIPS adjustments 9 MIPS adjustments 10 5

Participation Individual: single NPI tied to a single tax ID Report via o Electronic Health Record o Registry o Qualified clinical data registry o Claims Group: Set of clinicians sharing a common tax ID Report via o CMS web interface (register by June 30, 2017) o Electronic Health Record o Registry o Qualified clinical data registry 11 MIPS 12 6

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Report 6 quality measures 1 must be an outcome measure (or high-priority) Outcome measures are the golden child of measure types because they show a patient s health outcome after a clinical action was taken 271 measures to choose from 64 are outcome and 168 are high priority The rest are process or structure 15 CMS-calculated measures Data prevents complications that lead to hospital admissions Focus on the delivery of primary care and may not apply to many specialties o Bacterial pneumonia, UTIs, diabetes, COPD, heart failure No data needs to be submitted because it is collected from claims 16 8

Provider submitted measures: 80% of these the 271 measures are specialty specific. There are 26 specialty sets to make it easier to pick meaningful measures. If there are fewer than six measures in your specialty set, just report the whole set. One must be outcome, or pick a high-priority measure if there isn t one. 17 Provider submitted measures: Measures should be reported for at least 50% of Medicare part B beneficiaries for at least 90 days. Groups that report via the CMS web interface report the 15 measures listed there for the entire year. 18 9

Measures are created by CMS with input from all interested parties and they go through peer review journals each year. Core Quality Measures Collaborative (CQMC), a partnership between CMS and America s Health Insurance Plans (AHIP) aligns measures and develops consensus. 19 Clinical Quality Measures (CQMs) measure and track: o Health outcomes o Clinical processes o Patient safety o Efficient use of healthcare resources o Care coordination o And more. qpp.cms.gov and pqrs.cms.gov/#/home to learn more 20 10

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25 If using claims to report, make sure the practice s billers and coders become familiar with the numerator criteria and quality data codes (Gcodes) for each of the selected quality measures. These measures will contribute to the quality score and be available on Physician Compare 26 13

Two performance measures (PQRS 131 and 182) are denominator eligible for chiropractic patients (the claim has 98940, 98941, or 98942 on it). The numerator for these measures is to report Quality-Data Codes (QDCs), more commonly known as G-codes from HCPCS. 27 Measure #131 Pain Assessment and Follow-up Measure #182 Functional Outcomes Assessment Report on at least 50% of your Medicare patients over the age of 18 treated with CMT codes (98940, 98941, 98942). 28 14

Measure #131 Pain Assessment and Follow-up Percentage of patients aged 18 years and older with documentation of a pain assessment through discussion with the patient including the use of a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present. Pain Assessment is clinical assessment of pain through discussions with the patient and use of a standardized tool on the presence and characteristics of pain which may include location, intensity, quality, and onset/duration Examples of tools include Visual Analog Scale (VAS) Verbal Numeric Rating Scale (VNRS) Faces Pain Scale (FPS) Oswestry Disability Index (ODI) Roland Morris Disability Questionnaire (RMDQ) 29 Measure #131 Pain Assessment and Follow-up Percentage of patients aged 18 years and older with documentation of a pain assessment through discussion with the patient including the use of a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present. G8730: Pain assessment documented as positive using a standardized tool and a follow-up plan is documented. G8731: Pain assessment documented as negative, no follow-up plan is required. 30 15

Measure #131 Pain Assessment and Follow-up Percentage of patients aged 18 years and older with documentation of a pain assessment through discussion with the patient including the use of a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present. G8442: Documentation that patient is not eligible for pain assessment. G8732: No documentation of pain assessment. G8509: Positive pain assessment, but no follow up plan, no reason. G8939: Pain assessment documented, no follow-up plan, patient not eligible. 31 Measure #131 Pain Assessment and Follow-up Percentage of patients aged 18 years and older with documentation of a pain assessment through discussion with the patient including the use of a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present. This measure is to be reported for each visit occurring during the reporting period that bill with 98940, 98941, or 98942. Medicare example: Return in two weeks for re-assessment of pain ChiroCode example: Pain rated 5/10. Patient will be evaluated at next visit to determine effect of treatment on their current pain level. (G8730) 32 16

Measure #182 Functional Outcomes Assessment Percentage of patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool AND documentation of a care plan based on identified functional outcome deficiencies. Functional outcome assessment questionnaires are designed to measure a patient s limitations in performing the usual tasks of daily living. May include restricted ROM, back pain, neck pain, pain in joints, arms, or legs, and headaches Standardized tools include Oswestry Disability Index, Roland Morris Questionnaire, Neck Disability Index, Physical Mobility Scale, and others (not VAS). 33 Measure #182 Functional Outcomes Assessment Percentage of patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool AND documentation of a care plan based on identified functional outcome deficiencies. Functional outcome assessment tool should be used at a minimum of every 30 days, but reported on every visit. A care plan is an ordered assembly of expected or planned activities, including observation goals, services, appointments and procedures, usually organized in phases or sessions, which have an objective of organizing and managing health care activity for the patient. Deficiency is impairment or loss of function 34 17

Measure #182 Functional Outcomes Assessment Percentage of patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool AND documentation of a care plan based on identified functional outcome deficiencies. G8539: Documentation of a current functional outcome assessment using a standardized tool and documentation of a care plan based on identified deficiencies. G8942: Documented functional outcomes assessment and care plan within the previous 30 days. (New code 2013) G8542: Documentation of a current functional outcome assessment using a standardized tool; no functional deficiencies identified, care plan not required 35 Measure #182 Functional Outcomes Assessment Percentage of patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool AND documentation of a care plan based on identified functional outcome deficiencies. G8539: First visit and re-exams G8942: Every visit in-between G8542: Discharge visit maybe Example: Suzie Derkins scored a 42 on the Neck Disability Index at last evaluation. The goal is to improve by 50% by 5/21/17. (G8942) 36 18

Claims-based reporting Only available to individual ECs Use when ICD-10 and CPT codes appear on the claim and meet the measure criteria 74 measures can be reported this way in 2017 Must report for 50 percent or more of the EC s Medicare Part B patients for a continuous 90 days during 2017 39 Registry-based reporting Available to individual and group ECs 221 measures can be reported this way in 2017 Registry acts as a HIPAA Business Associate Must report for 50 percent or more of the EC s patients who fit within the measure denominator from all payers during the reporting period. 40 20

EHR-based reporting Available to individual and group ECs A limited number of measures based on information collected in the HER can be reported this way in 2017. EHR must be able to generate QRDA files. Must report for 50 percent or more of the EC s patients who fit within the measure denominator from all payers during the reporting period. 41 Qualified Clinical Data Registry-based reporting Available to individual and group ECs Specialty societies and associations create QCDRs and they can take the place of MIPS Quality measures. May report on all patients from all payers during the reporting period. 42 21

Web interface reporting Available to group ECs Must report all measures on the interface for the first 248 beneficiaries, or 100% of assigned patients May report on all Medicare Part B patients during the full year. Certified Survey Vendor can administer Consumer Assessment for Clinicians and Groups (CAHPS), which can be used by groups. 43 Scoring the Quality Category Benchmarks baseline performance by ECs based on two years previous to current performance period, if available. 10-point scoring system o Missing measures = 0 points o Minimum floor will safeguard against unexpected poor performance. Three points per measure, as long as you report. Bonus points are earned for reporting outcomes, patient experience or safety, appropriate use, and end-to-end EHR reporting. 44 22

Scoring the Quality Category Quality scoring is broken into ten categories, or deciles, reflecting 1 to 10 points. Those in the top decile will receive the maximum 10 points. ECs who do not report enough measures will receive 0 points for each measure not reported. An exception is made is insufficient measures are available. Measure validation ensures that ECs are submitting the proper measures, especially when submitting fewer than 6. 45 46 23

ACI is more customizable and flexible than MU No longer all-or-nothing Eliminates redundant Clinical Quality Measures (CQMs) Offers multiple paths Computerized Provider Order Entry (CDOE) and Clinical Decision Support (CDS) are de-emphasized Some Eligible Clinicians (ECs) can have their ACI score transferred to the Quality category of MIPS 47 Two objectives and measures sets: If you have a 2015 CEHRT: o Advancing Care Information Objectives & Measures (15 measures) If you have 2014 CEHRT: o 2017 Advancing Care Information Transition Objectives & Measures (11 measures) 48 24

Five Required ACI Objectives Protect patient information: Security Risk Analysis e-prescribing Provide Patient Access Health Information Exchange: o Send Summary of Care o Request/Accept Summary of Care 49 Required ACI Objectives 1. Protect patient information: Security Risk Analysis Protect PHI through required safeguards o Review security o Implement updates o Correct deficiencies Report yes/no statement 50 25

Required ACI Objectives 2. E-prescribing Create/send prescriptions electronically Numerator: # of prescriptions queried for a drug formulary and transmitted electronically Denominator: # of prescriptions written during performance period 51 Required ACI Objectives 3. Patient electronic access Provide at least one patient with timely access to View, Download, and Transmit (VDT) health info Numerator: # of patients who have access to VDT Denominator: # of patients seen by the EC during the reporting period 52 26

Required ACI Objectives 4. Health Information Exchange: Send a summary of care For at least one patient that is transitioned or referred elsewhere, create a summary of care and exchange it electronically Numerator: # of transitions or referrals where a summary is created using CEHRT and exchanged Denominator: # of transitions of care and referrals during 53 performance period where EC made a referral or transition Required ACI Objectives 5. Health Information Exchange: Request or accept summary of care For at least one patient that is transitioned or referred elsewhere, receive or retrieve a summary of care electronically Numerator: # of encounters where a summary is incorporated into the CEHRT Denominator: # of encounters during performance period where EC received referral or transition 54 27

Optional ACI Objectives for ECs using 2015 CERHT Patient electronic access: Timely access to health info and education Coordination of care through patient engagement: View Download or Transmit (VDT) health info to a third party Secure message sent to patient Patient-generated health data captured by CEHRT 55 Optional ACI Objectives for ECs using 2015 CERHT Health Information Exchange: Clinical information reconciled for medication, medication allergies, and review of patient s problem list. Public health and clinical data registry reporting: Immunization registry reporting to IIS Syndromic surveillance reporting for urgent care Electronic case reported to public health agency Public health registry reporting 56 Clinical data registry reporting 28

Optional ACI Objectives for ECs using 2014 CERHT Patient electronic access: Timely access to View Download or Transmit (VDT) health info VDT health info to a third party Patient Specific Education: Clinically relevant information provided electronically 57 Optional ACI Objectives for ECs using 2014 CERHT Secure messaging: Send a secure message via CEHRT Health Information Exchange: Use CEHRT to create summary of care and electronically transmit to a clinician for at least one transition of care or referral. 58 29

Optional ACI Objectives for ECs using 2014 CERHT Medication reconciliation: Reconcile medication list, medication allergy list, and current problem list for a transition of care or referral Public health reporting: Immunization registry reporting to IIS Syndromic surveillance reporting for urgent care Specialized reporting to a registry 59 Overall ACI percentage score = base score + performance score + bonus points Base score earns 50 percentage points for completing the required measures. o If all required measures are not reported, no ACI points can be given Performance score, calculated based on the numerator/denominator for each measure, can earn 60 up to 90 more percentage points 30

Overall ACI percentage score = base score + performance score + bonus points Bonus points can add another 15 percentage points. They come from: Reporting public health and clinical data registry reporting measures (5% bonus) Using CHERT to complete some Improvement Activities (10% bonus) (i.e. enabling special features in patient portal) 155 percentage points are possible, but the max ACI score is 25. 61 Example: 85/100 performance rate for a single measure would earn 9 percentage points towards the performance score for the ACI category. 62 31

Most solo practitioners need to attest that you completed for a minimum of 90 days: 2 improvement activities 93 to choose from, across 8 categories, 14 have a high activity weighting Clinicians can select IAs that align with clinic goals for improvement 63 64 32

Activities are weighted high (20 points) or medium (10 points). Groups with fewer than 15 ECs need to attest to a combination of activities equaling 20 points Groups need 40 points Full credit is given for achieving 60 points 65 66 33

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69 Compares resources used to treat similar care episodes and clinical condition groups across practices. May be risk adjusted Will be calculated from adjudicated claims. No reporting required. 70 35

2017 performance year data will be used as a baseline, but weight for 2019 is zero. 2020 weight will be 10% of MIPS composite score 2021 weight will be 30% Cost measures include: o Total per capita cost o Medicare Spending Per Beneficiary (MSPB) 71 Patients will be attributed to a PCP who provided a plurality of their primary care services, or evaluation and management services. Attribution threshold is 20 beneficiaries for the total per capita cost. The threshold is 35 beneficiaries for the MSPB measure. 72 36

1-10 points are assigned to each measure based on relative performance Benchmarks are determined by cost data from the performance period Max score is dependent on how may measures CMS attributes to the provider 73. Results in a Composite Performance Score (CPS) from 0-100. Ask CMS for your Quality Resource and Use Report (QRUR) 74 37

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77 What Now? Keep in contact with your electronic health record vendor. They should be able to help. Sign up for email updates at ChiroCode.com or FindACode.com To help individuals or groups of less than 15 clinicians MACRA set aside $20 million per year for 5 years to fund training and education. Should have rolled out locally in December of 2016 78 39

https://mips.qvhsystems.com/mips/fac 40