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)

Medicare Updates -- SNF, Neurostimulators, Ambulance Fee Schedule and more (2022-10-20)
October 27th, 2022 - CMS - MLNConnects
Skilled Nursing Facility Provider Preview Reports: Review by November 14 - Help Your Patients Make Informed Health Care Decisions - Ambulance Fee Schedule: CY 2023 Ambulance Inflation Factor & Productivity Adjustment - Compliance - Implanted Spinal Neurostimulators: Document Medical Records - Claims, Pricers, & Codes...
2023 Evaluation & Management Updates Free Webinar
October 24th, 2022 - Aimee Wilcox
Congratulations on a successful 2021 implementation of the Evaluation and Management (E/M) changes! That was a big change, but now an even bigger change is headed your way for inpatient and all other E/M categories. How great is it that almost all of the E/M categories will now be scored based on medical decision making (MDM) or total provider time? Standardized scoring and one set of E/M guidelines has the potential of bringing about a change or improvement of provider fatigue due to over regulation and documentation burden.
Are Leading Queries Prohibited by Law or Lore?
October 13th, 2022 - Erica E. Remer
AHIMA released its CDI Practice Brief Monday. At Yom Kippur services, I found myself thinking about the question Dr. Ronald Hirsch posed to me the day before. My rabbi was talking in her sermon about the difference between halacha and minhag. Halacha is law; it is the prescriptions...
2023 ICD-10-CM Guideline Changes
October 13th, 2022 - Chris Woolstenhulme
View the ICD-10-CM Guideline Changes for 2023 Chapter 19 (Injury, poisoning, and certain other consequences of external causes [S00-T88])The guidelines clarify that coders do not need to see a change in the patient’s condition to assign an underdosing code. According to the updated guidelines, “Documentation that the patient is taking less ...
Z Codes: Understanding Palliative Care and Related Z Codes
October 11th, 2022 - Gloryanne Bryant
Palliative care is often considered to be hospice and comfort care. Palliative care is sometimes used interchangeably with “comfort care” and then again sometimes with “hospice care.”  But these terms do have slightly different meanings and sometimes the meaning varies depending on who is stating it. The National...
2023 ICD-10-CM Code Changes
October 6th, 2022 - Christine Woolstenhulme, CPC, CMRS, QCC, QMCS
In 2022 there were 159 new codes; the 2023 ICD-10-CM code update includes 1,176 new, 28 revised, and 287 deleted codes, a substantial change from last year. The 2023 ICD-10-CM codes are to be used for discharges from October 1, 2022 through September 30, 2023, and for patient encounters from ...
Yes, You Have What It Takes To Lead Your Practice And Your Profession
September 20th, 2022 - Kem Tolliver
If you’ve been in any healthcare role for more than two years, you’ve seen quite a bit of change. And guess what, it’s not over. We are living and working in uncertain times. This climate requires each of us to step outside of our comfort zones to lead exactly where we stand. It’s not required of one to have a “title” to lead. What is required, however, is a willingness to trust your instincts, look for answers and rely on your team.



Home About Contact Terms Privacy

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

Copyright © 2000-2022 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association