Payment Rulings and Small Provider Practices

November 6th, 2017 - Wyn Staheli, Director of Research
Categories:   Reimbursement   MIPS|PQRS|PQRI   Billing  
0 Votes - Sign in to vote or comment.

Fall has always been the season for CMS fee changes and on November 2, 2017, CMS announced the finalization of four rules which directly impact the following payment systems:

  1. Physician Fee Schedule Final Policy, Payment, and Quality Provisions for CY 2018
  2. Hospital OPPS and ASC Payment System and Quality Reporting Programs Changes for 2018
  3. HHAs: Payment Changes for 2018
  4. Quality Payment Program Rule for Year 2

Of these four rulings, the physician fee schedule rule and the Quality Payment Program Rule are the most applicable to those in a smaller healthcare office. Please note that these rulings do change some of the information that was included in Chapter 2 and Chapter 6 of Find-A-Code's specialty-specific Reimbursement Guides.

This article only contains a brief overview of some of the key points more relevant to the smaller healthcare practice. To read a more comprehensive analysis of all four rulings, see “Four Final Rules Affecting CMS Payments for 2018”.

Physician Fee Schedule

This final rule includes a new Patients over Paperwork initiative, RVU changes, and much more. When considering fees, always keep in mind that fees are adjusted based on quality program initiatives.

The following are some highlights from the Final Rule:

  • Conversion factor for 2018 is set as $35.99 (an increase from $35.89 for 2017)
  • New Patients Over Paperwork Initiative which, according to a CMS press release, is  “...a cross-cutting, collaborative process that evaluates and streamlines regulations with a goal to reduce unnecessary burden, increase efficiencies, and improve the beneficiary experience”
  • RVU changes:  As always, CMS reviewed potentially misvalued RVUs and there were quite a few changes. Some specialties are impacted more than others (e.g., some behavioral health services have some RVU increases.) As soon as RVUs are made available, they will be included in FindACode.com in the "RVUs - Relative Value Units" portion of the code information page. 
  • Request for comments regarding Evaluation and Management guidelines (there were no guideline changes in the Final Rule)
  • Patient relationship codes required under section 101(f) of MACRA will be reported with new HCPCS modifiers (CLICK HERE to read more about this)
  • Medicare Shared Savings Program modified in an effort to reduce reporting burdens and streamline program operations (see Chapter 2.1 in Find-A-Code's specialty-specific Reimbursement Guides for more information about this program)

CLICK HERE to read the Press Release.

CLICK HERE to read the Final Rule.

Quality Payment Program Rule for Year 2

CMS kept some of the transition year policies and made some other changes designed to reduce the burden of provider participation. Please note that there were some changes from the Proposed Rule. Some key points are:

  • Exemptions increased: fewer providers will be impacted by MIPS since the low volume threshold has been increased to ≤ $90,000 in Part B allowed charges OR ≤ 200 Medicare beneficiaries (from ≤ 30,000 OR ≤ 100 beneficiaries in the Proposed Rule)
  • MIPS scoring changes:
    • Cost performance category will be 10% instead of 0%
    • Quality performance category will be 50% instead of 60%
  • Adding 5 bonus points to the MIPS final scores of small practices (15 or fewer clinicians)
  • Adding Virtual Groups as a participation option (See Chapter 2.5 in Find-A-Code's specialty-specific Reimbursement Guides)
  • Raising the MIPS performance threshold to 15 points in Year 2 (last year it was 3 points)
  • Allowing the use of the 2014 Edition and/or 2015 Certified Electronic Health Record Technology (CEHRT) in Year 2 for the Advancing Care Information performance category, and giving a bonus for using only 2015 CEHRT
  • Awarding up to 5 bonus points on your MIPS final score for treatment of complex patients
  • Automatically weighting the Quality, Advancing Care Information, and Improvement Activities performance categories at 0% of the MIPS final score for clinicians impacted by Hurricanes Irma, Harvey, and Maria, and other natural disasters
  • Issuing an interim final rule with comment for extreme and uncontrollable circumstances where clinicians can be automatically exempt from these categories in the transition year without submitting a hardship exception application
  • Providing more detail on how eligible clinicians participating in selected Advanced Alternative Payment Models (APMs) will be assessed under the APM scoring standard

Note: See Chapter 2.4 of Find-A-Code's specialty-specific Reimbursement Guides for more about the Quality Payment Program.

CLICK HERE to read the Final Rule Overview.

CLICK HERE to read the Executive Summary.

CLICK HERE to read the Press Release.

CLICK HERE to read the Final Rule.

###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Latest articles:  (any category)

​​Polysomnography Services Under OIG Scrutiny
September 2nd, 2021 - Raquel Shumway
The OIG conducted a study dated June 2019 wherein they indicated that there were approximately $269 million in overpayments for polysomnography services for the period of 2014 through 2015. According to the OIG “These errors occurred because the CMS oversight of polysomnography services was insufficient to ensure that providers complied with Medicare requirements and to prevent payment of claims that didn’t meet those requirements.” So what are those requirements?
Medicare Advantage - The Fastest Growing Government-Funded Program Undergoing Multiple Fraud Investigations
August 16th, 2021 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
Medicare Advantage is the fastest growing form of government-funded healthcare and the rate of fraud within this segment has come under increased scrutiny. Funding is determined by the health status of each beneficiary; therefore, accurate coding based on detailed documentation makes the medical record vital to the process because some ...
Billing Dental Implants under Medical Coverage
August 12th, 2021 - Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
Implants can be costly to the patient and the provider, and it is crucial to understand how to bill a patient’s medical insurance to ensure there is adequate coverage for the best treatment. Implants are commonly billed in a dental office under a patient’s medical benefits.    Implants could be considered ...
New Codes for COVID Booster Vaccine & Monoclonal Antibody Products
August 10th, 2021 - Wyn Staheli, Director of Research
New codes have been announced for the COVID-19 booster vaccine, Novavax vaccine, and monoclonal antibody treatment.
Medicare's ABN Booklet Revised
July 29th, 2021 - Wyn Staheli, Director of Research
The “Medicare Advance Written Notices of Non-coverage” booklet, published by CMS’s Medicare Learning Network, was updated. This article discusses the changes to this booklet regarding the use of the ABN.
Chronic Pain Coding Today & in the Future
July 19th, 2021 - Wyn Staheli, Director of Research
Properly documenting and coding chronic pain can be challenging. As is commonly the case with many conditions, over the years, there has been a shift in the identification of different types of pain, including chronic pain. Understanding where we are now and where we are going will help your organization prepare for the future by changing documentation patterns now.
How Does Global and Professional Direct Contracting (GPDC) Affect Risk Adjustment?
July 15th, 2021 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
CMS recently announced the 53 Direct Contracting Entities (DCEs) that will be participating in the April 1, 2021 through December 31, 2021 Global and Professional Direct Contracting (GPDC) Model. Among those participating is Clover Health Partners, who runs an in-home primary care program that has the potential to help Medicare ...



Home About Contact Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2021 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association