by elizabeth w. woodcock, mba, facmpe, cpc 2016... · elizabeth w. woodcock, mba, facmpe, cpc...

By Elizabeth W. Woodcock, MBA, FACMPE, CPC

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Elizabeth W. Woodcock, MBA, FACMPE, CPC

Speaker, Author, Trainerwww.elizabethwoodcock.com� MBA, Wharton School of Business, University of Pennsylvania

� BA, Duke University

� Fellow, American College of Medical Practice Executives

� Certified Professional Coder

� Author, 15 textbooks and more than 500 Articles

� Founder and Principal, Woodcock & Associates

� Former Consultant, Medical Group Management Association; Group

Practice Services Administrator, University of Virginia Health Services

Foundation; Former Senior Associate, Health Care Advisory Board

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� Federal Government� New Payer in the Market� Meaningful Use

� ICD10� PQRS

� VBPM� Penalties � Future

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2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Law

Actual

Exception - 2014Q1 had a 0.5% rate increase

-0.77%

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CARC CO253Adjustment code for mandated Federal, State

or Local law/regulation

CARC=Claim adjustment reason code

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CPT Descriptor2015

wRVU

Proposed

2016 wRVU

Final

Work RVU

Final % Change

45330 Flexible sigmoidoscopy 0.96 0.77 0.84 -13%

45378 Colonoscopy 3.69 3.29 3.36 -9%

45380 Colonoscopy w/ Biopsy 4.43 3.59 3.66 -17%

45382 Colonoscopy w/ Control of Bleeding 5.68 4.76 4.76 -16%

45388Colonoscopy, Flexible with Ablation 5.86 4.98 4.98 -15%

Revaluing of the lower GI

endoscopy codes, including…

Pathology – 8% Increase

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Average cuts based on claims processed under the taxonomy

code associated with the specialty; represents RVU changes

only. Includes physician specialties only. All other specialties

0% impact.

Review Your Appendix

Pathology 8% Gastroenterology -4%

Interventional Radiology 1% Radiation Oncology -2%

Dermatology 1% Neurosurgery -1%

Plastic Surgery 1% Neurology -1%

Colorectal Surgery -1%

Nuclear Medicine -1%

Ophthalmology -1%

Physical Medicine & Rehab -1%

Vascular Surgery -1%

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99497 Advance care planning including the explanation and discussion of

advance directives such as standard forms (with completion of such

forms, when performed), by the physician or other qualified health professional; first 30 minutes, face-to-face with the patient, family

member(s) and/or surrogate

+ Add-on 99498 … each additional 30 minutes

CPT Work RVU

99497 1.50

99498 1.40

Subject to Cost-Sha

ring

except when billed w

ith

an AWV

•Modifier -33

•Separately payable

AWV = Annual Wellness Visit (Medicare) 8

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99490 Chronic Care Management Services

99495 and 99496 Transitional Care Management

DOS: Date of the E/M Visit

[in contrast to the final day of the

30-day period post-discharge]

“Direct”supervision is

required

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Supervising = Billing

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“…we continue to seek a better understanding regarding the growing trend toward hospital acquisition of physicians’ offices and how the subsequent treatment of

those locations as off-campus provider-based outpatient departments affects payments under PFS and beneficiary cost-sharing.”

-CMS 2015 Medicare Physician Fee Schedule Final Rule (11/14)

-22 – On-C[mpus

-19 – Off-C[mpus

Effective January 1, 2016

New Place of Service CodesHospital Outpatient Departments (OPDs)

250 Yards

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• Halted all Provider-based

Billing Site Differential

Payments Made to Off-

Campus Hospital Outpatient Departments (OPDs) as of

January 1, 2017. All OPDs

that were in place as of

November 2, 2015 are exempt (grandfathered)

• Extended Sequestration for

One More Year – through

December 31, 2025

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Primary Care Incentive Program (PCIP)

2011-2015*

Medicare reimbursement: Bonus of 10% of payments

for selected codes, paid quarterly

•Primary care (IM, FP, Peds, Geriatrics; Physicians, NPs,

PAs and CNSs) for whom primary care services account

for at least 60% of allowed charges – based on the

definition, may include advanced practice providers

working with a specialist

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*Dates of service January 1, 2011 through December

31, 2015

HPSA Surgical Incentive

Payment (HSIP)

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69209the removal of impacted cerumen using irrigation/lavage

(unilateral)

99415-6 Prolonged, face-to-face clinical staff services under direct

supervision

99406-9 Behavior change intervention can be reported with a -25 modifier

in addition to preventive services

Changes

Also… Vaccines | Radiology | Respiratory | Urinary… and

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Commercial

Government

Self 100%

<5%

50%

5%

35%

60%

32%32%32%32%

Source: Woodcock & Associates analysis of professional fee receivables, 2015.

Patient Financial

Responsibility

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1st

Year

Meaningful Use Annual Incentive Payments

2011 2012 2013 2014 2015 2016 [….] TOTAL

2011 MCR $18,000 $12,000 $8,000 $4,000 $2,000 $0 $0 $44,000

MCD $21,250 $8,500 $8,500 $8,500 $8,500 $8,500 $0 $63,750

2012 MCR $18,000 $12,000 $8,000 $4,000 $2,000 $0 $44,000

MCD $21,250 $8,500 $8,500 $8,500 $8,500 $8,500 $63,750

2013 MCR $15,000 $12,000 $8,000 $4,000 $0 $39,000

MCD $21,250 $8,500 $8,500 $8,500 $17,000 $63,750

2014 MCR $12,000 $8,000 $4,000 $0 $24,000

MCD $21,250 $8,500 $8,500 $25,500 $63,750

2015 MCR $0 $0 $0 $0

MCD $21,250 $8,500 $34,000 $63,750

2016 MCR $0 $0 $0

MCD $21,250 $ 42,500 $63,750

MCR = Medicare; MCD = Medicaid. MCD participants must begin participation by 2016.

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CMS Final RuleOctober 16, 2015

[Last Day to Start in Order to Get the

90 Days in]

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Eliminated!!• Patients who secure electronic

message• Patients who download, view online or

transmit to a third party their health

information electronically

Stages are Collapsed = “Modified Stage Two”

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1. Protect Electronic Health Information2. Clinical Decision Support (CDS)– 5 rules for 4+ CQMs or high priority

health conditions; drug-drug and drug-allergy interaction checks3. CPOE – 60% meds; 30% lab and radiology orders4. ePrescribing – 50% queried for drug formulary and transmitted

electronically5. Summary of Care – create and transmit for 10% transitions of care and

referrals

6. Patient-specific education – 10% of all unique patients7. Medication reconciliation – 50% of all transitions of care

8. Patient electronic access – 50% provided access within 4 business days; one patient views, downloads or transmits

9. Secure electronic messaging – [Y or N] – capability?

10. Public Health/Clinical Data Registry Reporting

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Based on Using “Exceptions” –

1.Protect Electronic Health Information

2.CDS – 1 rule relevant to specialty/high clinical priority

3.CPOE – 30% medications only4.ePrescribing – 40% transmitted electronically

5.Patient electronic access – 50% provided access

within 4 business days6.Public Health/Clinical Data Registry Reporting –

same as Modified Stage Two

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[EHR Incentive Programs] If an EP, eligible hospital or Crit ical Access Hospital (CAH) is unable to

effectively plan for a report ing period in 2015 due to the timing of the publication of the 2015 through

2017 Modificat ions final rule, can they apply for a hardship exception?Yes, if a provider is unable to meet the requirements of meaningful use for an EHR report ing period in

2015 for reasons related to the timing of the publication of the final rule, a provider may apply for a

hardship exception under the "extreme and uncontrollable" c ircumstances category. Each hardship

exception application will be reviewed on a case-by-case basis, as required by law.In the past, CMS has considered these applications seriously and, in fact, has approved over 85% of

hardship exemptions.

(FAQ 12845)

Source: https://questions.cms.gov/faq.php?id=5005&faqId=12845

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� First, EPs scheduled to be in Stage 1 may attest to only 1 public health

measure instead of 2...

� Second, we will allow providers to claim an alternate exclusion for a

measure if they did not intend to attest to the equivalent prior menu

objectiveSource: CMS https://questions.cms.gov/faq.php?id=5005&faqId=12985

Examples:

Rheumatology Informatics System for Effectiveness (RISE)

GIQuIC Colonoscopy Quality Registry

Digestive Health Recognition Program Registry

DataDerm™ registry

State Cancer Registry -

http://epi.grants.cancer.gov/registries.html#state

Not meant to be an exhaustive list

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•Transmitted via email

•Review the audit request – complete? limited (to one measure)?

•Retain documentation for 6 years

•CMS – and (2015) OIG

http://go.cms.gov/1J6buIshttp://bit.ly/1dB9eg3

Audit InformationGovernment Sample

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DATE OF SERVICE

2015

“The Secretary of Health and Human

Services may not, prior to October 1,

2015, adopt ICD–10

code sets as the standard for code

sets…”

Source: Protecting Access to Medicare Act, April 1, 2014

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V91.07XD

Burn due to water-skis

on fire, subsequent

encounter

Denials??CO11 - The diagnosis is inconsistent w ith the procedure. (…or Age, Gender or Provider Type)CO16 - Claim/service lacks information or has submission/billing error(s) w hich is needed for adjudication.

CO50 - These are non-covered services because this is not deemed a 'medical necessity' by the payer.CO146 - Diagnosis w as invalid for the date(s) of service reported.

CO15 - The authorization number is missing, invalid, or does not apply to the billed services or provider.

ICD10 - The code is wrong.

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Metrics October 1-27, 2015 Historical Baseline*Total Claims Submitted 4.6 million per day 4.6 million per day

Total Claims Rejected

due to incomplete or invalid information

2.0% of total claims submitted

2.0% of total claims submitted

Total Claims Rejected due to invalid ICD-10

codes

0.09% of total claims

submitted

0.17% of total claims

submitted

Total Claims Rejected

due to invalid ICD-9

codes

0.11% of total claims

submitted

0.17% of total claims

submitted

Total Claims Denied10.1% of total claims

processed

10% of total claims

processed

*Metrics for total ICD-9 and ICD-10 clai ms rejecti ons w ere es ti mated based on end-to- end testing conducted in 2015 si nce CMS has not historically collected this data. Other metrics are based on

historical clai ms submissions.

Source: CMS, https:/ /www.cms.gov/Newsroom/Medi aReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-10-29.html

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1. No denials on the basis of specificity (only)

for 12 months.2. Advance payments available.

3. Ombudsman.

Humana and United said… they had

adopted a liberal approach to specificity

as long as the codes made sense…~10/15 MGMA “Town Hall” meeting, as reported by Robert Tennant, senior pol icy adv isor for the Medic al Group Management Association

July 2015

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2015 PQRS Implementation

2015 PQRS Implementation Guide: Guide:

http://go.cms.gov/1aI1SXl

http://go.cms.gov/1aI1SXlMeasures:

Measures:

http://go.cms.gov/1ev2vjp

http://go.cms.gov/1ev2vjp

Can also qualify for MU CQMs

2+ Eligible ProfessionalsCan also qualify for MU CQMs

Can report 1 measures group

Not limited to PQRS measures

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2016-2%*

281 Measures & 18 in GPRO

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Size of

Group

Paymt

Adj’mt

Perf’ce

Year

100+ 2015 2013

10+ 2016 2014

All 2017 2015

Automatic Penalty

1% (2015)*

2% (2016)+

2% for <9 EPs; 4% for >9 (2017)+

*Must have reported through GPRO

+GPRO – or at leas t 50% of the EPs in the TIN must have reported. The exception is

solo practitioners, w ho mus t participate success fully.

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Cost measures, including total per capita, condition-specific, and spending per hospital patient

Quality measures, including

hospital admissions for ambulatory care sensitive conditions

and all-cause hospital readmissions

Except M

CR Part

D outp

atient

presc

riptio

n drugs

Exempt if <125 cases

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Download your Quality and Resource Use Report Today!

You’ll need an IACS (Individuals Authorized Access

to the CMS Computer Services) user ID and

password

You won’t get one if you participate in the Medicare Shared

Savings Program, the Pioneer ACO Model, or the Comprehensive Primary Care Initiative

http://go.cms.gov/1JjoXvb

Read CMS’ Document “Action for Physicians… to Take In Order To

Earn an Incentive Based on Performance and Avoid the Automatic CY

2017 Downward Payment Adjustment under the VBPM”!

1.1.

2.2.

http://go.cms.gov/1DtymQu

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Year eRx PQRS EHR VBPM+

Seques-

tration~ Total

2012 -1.0% - - - - -1.0%

2013 -1.5% - - - -2.0% -3.5%

2014 -2.0% - - - -2.0% -4.0%

2015 - -1.5% -1.0% -1.0% -2.0% -5.5%

2016 - -2.0% -2.0% -2.0% -2.0% -8.0%

2017 - -2.0% -3.0% -4.0% -2.0% -11.0%

2018 - -2.0% up to -5% -4.0% -2.0% up to -13%

+\Table reports maximum penalty.~Applies only to Medicare payment, not the allowable

In 2013, the Sequestration cuts started in April of that year.

Applied to all Medicare reimbursement

2015 Performance

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However, every eligible professional will be assigned a “composite score”

Will replace PQRS, VBPM and MU!

1. Participate in an

Alternative Payment Model �

2. Low MCR volume

3. New provider

Category Yr 1

(2019)

Yr 2

(2020)

2021 +

Quality 50% 45% 30%

Meaningful Use* 25% 25% 25%

Resource Use 10% 15% 30%

Clinical Practice

Improvement

15% 15% 15%

Max. Reduction (4%) (5%) (7%-9%)

*MU weight can decreas e to 15% if adoption reaches 75%; the weight would then be

redistributed to another category.

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� Clinical Practice Improvement?

� Expanded practice access

� Population management

� Care coordination

� Beneficiary engagement

� Patient safety and practice assessment

or "comparable specialty practice"

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� Promoting health equality and continuity

� Accepting new Medicaid (MCD) patients

� Service MCD or MCR/MCD patients

� Participating in the ACA exchange

� Underserved populations

� Integration of behavioral health

� Emergency preparedness and response

PROPOSALPROPOSALPROPOSALPROPOSAL

October 2 015

MCD=Medicaid; MCR=Medicare

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Question &

Answer

Session

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Elizabeth W. Woodcock, MBA, FACMPE, CPC

Woodcock & Associates

Speaker, Trainer, Author

Atlanta, Georgia

404.373.6195

elizabeth@elizabethwoodcock.com

www.elizabethwoodcock.com

These handouts may not be reproduced without the written consent of the speaker.