cy 2017 final rule summary for radiation oncology · cy 2017 final rule summary for radiation...

CY 2017 Final Rule Summary for

Radiation Oncology

November 15, 2016

Presented for ACRO Members

Revenue Cycle Inc.

Contact Information

Revenue Cycle Inc.

1817 W. Braker Lane

Bldg. F, suite 200

Austin, Texas 78758

www.revenuecycleinc.com

[email protected]

(512) 583-2000

http://www.revenuecycleinc.com/

mailto:[email protected]

Presenters

Teri Bedard, BA, RT(R)(T), CPC

Director of Corporate Consulting

Amanda Klun, MBA, MSHA, RTT

Consultant

Housekeeping

• Everyone is muted

• If you have any questions please post under Q&A

• If you have an additional question that was not answered

during the webinar, please email us at

[email protected] and let us know you listened to

the ACRO final rule webinar

• Everyone who requests a pdf copy of presentation will be

emailed one

mailto:[email protected]

Disclaimer

This presentation was prepared as a tool to assist attendees in learning about documentation, charge

capture and billing processes. It is not intended to affect clinical treatment patterns. While reasonable

efforts have been made to assure the accuracy of the information within these pages, the responsibility

for correct documentation and correct submission of claims and response to remittance advice lies with

the provider of the services. The material provided is for informational purposes only.

Efforts have been made to ensure the information within this document was accurate on the date of

presentation. Reimbursement policies vary from insurer to insurer and the policies of the same payor

may vary within different U.S. regions. All policies should be verified to ensure compliance.

CPT® codes, descriptions and other data are copyright 2016 American Medical Association (or such

other date of publication of CPT®). All Rights Reserved. CPT® is a registered trademark of the

American Medical Association. Code descriptions and billing scenarios are references from the AMA,

CMS local and national coverage determinations (LCD/NCD).and standards nationwide.

Objectives of this Presentation

Basic Review of Reimbursement Settings

Discuss the Highlights HOPPS Final Rule Items

Discuss the MPFS Final Rule Items

Review MPFS Reimbursement Impact for 2017

Discuss the Quality Payment Program Final Rule per MACRA

HOPPS and MPFS Payment Systems

HOPPS

• Hospitals and ASCs

• Payments based on costs

• Adjusted by a wage index

• Grouped in APCs

• Example : Tx Plans

– 77295 & 77301

• Historically the same

payment rate under HOPPS

MPFS

• Physicians and Office Settings

• Codes have RVUs

• CF is applied to all RVUs

• GPCI’s

• Codes can be split into Global, TC,

26 payment

• Example: Tx Devices

– 77332, 77333, 77334

• Historically different payment

rates under MPFS

Federal Register

• Document actions of Federal agencies and forum for public

review and comment

• Publications include: Presidential Documents, Rule &

Regulations, Proposed Rules and Notices

Hospital Outpatient Prospective Payment

System (HOPPS)

Medicare Physician Fee Schedule

(MPFS)

Proposed vs. Final Rule

Proposed Rule:

• CMS plans, goals, solutions to

problems and proposed

rulemaking

• Opportunity for public to make

comments

Final Rule:

• Final legal effect after

consideration of comments

FINAL RULE

Consideration of Comments

+ Proposed

Rules

HOPPS Final Rule CY 2017

https://www.federalregister.gov/documents/2016/11/14/20

16-26515/medicare-program-hospital-outpatient-

prospective-payment-and-ambulatory-surgical-center-

payment

https://www.federalregister.gov/documents/2016/11/14/2016-26515/medicare-program-hospital-outpatient-prospective-payment-and-ambulatory-surgical-center-payment

























HOPPS 2017 Final Rule Highlights

• Increase in payments of 1.7%

• Changes to APCs, several codes are moving around and

reimbursements are adjusting

• Provider-based departments (PBDs)

– Excepted & Nonexcepted off-campus PBDs set

– Bill on UB04, paid at 50% of HOPPS fee & use G-codes

for treatments and IGRT

• Hospital Outpatient Quality Reporting (OQR) Program

– OP-33: External Beam Radiotherapy for Bone

Metastases

2016-2017 Hospital Outpatient Prospective Payment System National Average Course Example Impacts

Type HOPPS 2016 Course

Medicare Allowable

HOPPS 2017

Course Medicare

Allowable

2016 - 2017 Final

Rule Variance

2016- 2017

Final Rule %

Change

2D - 10 fxs $3,885.92 $4,060.50 $174.58 4.49%

3D - w/ imaging (33 fxs) $11,402.99 $11,850.26 $447.27 3.92%

3D - w/out imaging (33 fxs) $11,712.48 $12,238.06 $525.58 4.49%

IMRT - Simple 44 fxs $26,345.47 $26,042.12 ($303.35) -1.15%

IMRT - Complex 30 fxs $18,623.93 $18,415.06 ($208.87) -1.12%

SRS- Linac $9,180.54 $9,373.93 $193.39 2.11%

SRS- Cobalt Frame/Frameless (Same Day) $8,888.77 $9,062.50 $173.73 1.95%

SRS- Cobalt Frameless $9,180.54 $9,373.93 $193.39 2.11%

SBRT Linac 3 Fractions $11,499.46 $11,766.06 $266.60 2.32%

SBRT Linac 5 Fractions (Brain) $15,135.05 $15,378.67 $243.62 1.61%

SBRT - Cobalt 5 Fractions (Brain) $15,135.05 $15,378.67 $243.62 1.61%

Proton - 25 Fractions $31,611.91 $27,760.94 ($3,850.97) -12.18%

Prostate - HDR $11,490.68 $12,247.25 $756.57 6.58%

Prostate - LDR $9,442.13 $9,467.79 $25.66 0.27%

GYN - T&O - HDR $12,623.80 $13,464.05 $840.25 6.66%

GYN - Cylinder 1 Chan- HDR $5,445.00 $5,503.85 $58.85 1.08%

GYN - Cylinder Multi Chan - HDR $5,629.37 $5,697.75 $68.38 1.21%

APBI Single Channel - HDR $12,790.60 $12,638.10 ($152.50) -1.19%

APBI Multi Channel - HDR $12,974.97 $12,832.00 ($142.97) -1.10%

MPFS Final Rule CY 2017

https://www.federalregister.gov/documents/2016/11/15/2016-

26668/medicare-program-revisions-to-payment-policies-under-

the-physician-fee-schedule-and-other-revisions

https://www.federalregister.gov/documents/2016/11/15/2016-26668/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other-revisions






























Conversion Factor (CF) Update

• The Medicare Access and CHIP Reauthorization Act of 2015

(MACRA) put into law April 16, 2015

– CF to increase 0.5% each year through 2019

– CF 0% increase 2020 – 2025, additional payments based on

Quality Payment Program (MIPS)

– 2026 and beyond payments on participation in APMs

• 0.75% update for qualifying APMs

• 0.25% update for non-qualifying APMs

• Conversion Factor for 2017 = $35.8887

– Increase from 2016

Calculating Conversion Factor

• 2016 CF + 0.5% , then -0.013% budget neutrality factor to keep

CMS in the budget range of no more than $20 million high or low

• Target Recapture Amount = -0.18%

• Imaging MPPR (Multiple Procedure Payment Reduction) =

-0.07% , to offset payment adjustment changes effective 2017

MPFS Payment

• Work: Relative time and intensity of service

• Practice Expense (PE): Costs of maintaining practice, i.e. rent, supplies,

equipment

• Malpractice (MP): Costs of malpractice insurance

• Geographic Practice Cost Index (GPCI): Adjusts for geographic variation

in costs

• Conversion Factor (CF): Converts to dollar amount

MPFS Payment Impact Table

TABLE 52: CY 2017 PFS Estimated Impact on Total Allowed Charges by Specialty*

(A)

Specialty

(B) Allowed

Charges (mil)

(C)

Impact

of Work

RVU

Changes

(D)

Impact

of PE

RVU

Changes

(E)

Impact

of MP

RVU

Changes

(F)

Combined

Impact**

Radiation Oncology $1,726 0% 0% 0% 0%

Radiation Therapy Centers $44 0% 0% 0% 0%

** Column F may not equal the sum of columns C, D, and E due to rounding.

Geographic Practice Cost Index (GPCI)

• Factor applied to the reimbursement equation to account for

geographic location of provider and variation in costs of

furnishing services in the particular location

• Required to be reviewed and if necessary adjusted every 3

years

• Per MACRA the Work GPCI floor of 1.0 extended thru

12/31/17

• CY 2017 reviews completed and few items to address

– Frontier States 1.0 PE GPCI

– Fee Schedule Adjustments for State of California

Frontier States PE GPCI

• Frontier States include

– Montana, Wyoming, North Dakota, South Dakota and

Nevada

• Due to population/size of each state

– At least 50% of counties are considered frontier and

population per square mile is less than 6

– CMS is capping the PE (Practice Expense) GPCI at 1.0

for the Frontier States even if the value would be lower

than the “floor value”

Adjustments to CA GPCIs

• Per MACRA, beginning CY 2017 fee schedule areas for CA

must be Metropolitan Statistical Areas (MSAs) as defined by

the Office of Management and Budget (OMB) as of

December 31 of the previous year

• All areas not located in an MSA must be treated as a single

rest-of-state fee schedule area

• Change from 9 current localities to 32 in CY 2017

• Values to be implemented gradually over 6 year period in

increments of 1/6 each year

– 58 counties in CA, 50 in transition in 2017

Valuation of Specific Codes

• Codes evaluated on annual basis, the RUC recommends values by February

10th of each year in order to be considered, if late then put off until next year

– CMS evaluates recommendations and also reviews claims data, review

of medical literature, comparative databases, comparison to other codes

and discussion with physicians and other healthcare professionals before

deciding whether or not to accept the RUC’s recommendations or

establish different values

• CY 2017 Rad Onc code changes

– G6011

– 77332, 77333 and 77334

– 77470

– 77778 and 77790

PE RVUs for G6011

• Per PAMA (Patient Access and Medicare Protection Act) signed into

law 12/18/15 G-codes used for Tx & IGRT must maintain assigned

definitions, inputs and values for CY 2017 and CY 2018

• Code G6011 (complex treatment up to 5 MeV energy) decrease in non-

facility PE for 2017

• Due to claims data – from 2 specialties

– Data to set rate in 2016 showed 51% billed by dermatology & 43%

by radiation oncology

– Most recent data 85% radiation oncology & ~6% dermatology

• Can’t revalue code as norm, so adjusted PE due to specialty indirect

PE values assigned to rad onc vs. dermatology

– Change in Indirect PE impacts overall PE RVU for code

Valuation of 77332, 77333 & 77334

• Identified through high expenditure specialty screening tool

– RUC recommended no changes

– CMS believes current RVUs overstate work involved in furnishing

service of treatment devices

• Based on research, CMS found 34% decrease in total time to provide

service for code 77332

– RUC did not incorporate time into recommended value

• Due to incremental increase in work value (simple, intermediate and

complex) the intermediate (77333) and complex (77334) codes change

as well

• Code 77332 down $15.23 & 77334 down $21.17, but 77333 up $44.63!

Valuation of 77470

• Identified through high expenditure specialty screening tool

• Accepted value recommended by RUC for 2017

• Believe description of code and vignette describe different

and unrelated treatment being performed by the physician

and clinical staff for a typical patient

– Disparity between work RVUs and PE RVUs

• Work RVU for 2017 is 2.03 down from 2.09

• CMS expressed serious concerns how 77470 is valued and

coded

Valuation 77778 & 77790

• CY 2015 definition for 77778 did not include handling and

loading

– CY 2016 it was added to definition of 77778, but Work

RVU was not adjusted to account for it

• CY 2016 Interim work RVU for 77778 = 8.00 & 77790 = 0

• Discrepancies between the RUC and specialty society as to

what is included in 77778

– Pre-service time is not calculated same between groups

• Work RVU for 2017 set at 8.78 and PE RVU raised, an

increase in payment of $47.44

TABLE 27: Finalized CY 2017 Work RVUs for New, Revised and Potentially Misvalued Codes

HCPCS

code Long Descriptor

CY 2016

Work RVU

Proposed

CY 2017

Work RVU

Final CY

2017 Work

RVU

CMS Work

Time

Refinement

77332 Treatment devices, design and construction;

simple (simple block, simple bolus) 0.54 0.45 0.45 No

77333

Treatment devices, design and construction;

intermediate (multiple blocks, stents, bite

blocks, special bolus)

0.84 0.75 0.75 No

77334

Treatment devices, design and construction;

complex (irregular blocks, special shields,

compensators, wedges, molds or casts)

1.24 1.15 1.15 No

77470

Special treatment procedure (eg, total body

irradiation, hemibody radiation, per oral or

endocavitary irradiation)

2.09 2.03 2.03 No

77778

Interstitial radiation source application,

complex, includes supervision, handling,

loading of radiation source, when performed

8.00 8.00 8.78 No

77790 Supervision, handling, loading of radiation

source 0.00 0.00 0.00 No

Sedation Values Removed from Codes

• Trend in which sedation for certain procedures is performed

by different physician than endoscopy

– Resource costs are not incurred by endoscopic

procedure, need to change values to reflect this

• Separate sedation codes created by CPT Editorial

Committee – based on age of patient and if provider did

both the procedure & sedation or just one or other

• Several placement codes & hyperthermia treatments with

0.25 work RVU decrease due to removal of sedation from

value

TABLE 26: Valuations for Services Minus Moderate Sedation

CPT code CY 2016 Work RVU CY2017 Final Work RVU

Use HCPCS code

G0500 to Report

Moderate

Sedation

(Y/N)

19298 6.00 5.75 N

31626 4.16 3.91 N

32553 3.80 3.55 N

43253 4.83 4.73 Y

49411 3.82 3.57 N

57155 5.40 5.15 N

77600 1.56 1.31 N

77605 2.09 1.84 N

77610 1.56 1.31 N

77615 2.09 1.84 N

Reimbursements Due to RVU Changes in 2017

HCPCS Mod Description

2016 Final

Payment Rate

(CF$35.8043)

2017 Final

Payment Rate

(CF$35.8887)

Variance % Change

77332 Radiation treatment aid(s) $83.78 $68.55 ($15.23) -18.2%

77332 TC Radiation treatment aid(s) $55.14 $44.50 ($10.64) -19.3%

77332 26 Radiation treatment aid(s) $28.64 $24.05 ($4.60) -16.1%

77333 Radiation treatment aid(s) $53.71 $98.34 $44.63 83.1%

77333 TC Radiation treatment aid(s) $9.67 $58.86 $49.19 508.8%


77334 Radiation treatment aid(s) $154.32 $133.15 ($21.17) -13.7%

77334 TC Radiation treatment aid(s) $89.51 $72.50 ($17.02) -19.0%


77470 Special radiation treatment $157.90 $146.78 ($11.11) -7.0%

77470 TC Special radiation treatment $48.69 $39.48 ($9.22) -18.9%

77470 26 Special radiation treatment $109.20 $107.31 ($1.90) -1.7%

77778 Apply interstit radiat compl $789.13 $836.57 $47.44 6.0%

77778 TC Apply interstit radiat compl $372.01 $375.04 $3.03 0.8%

77778 26 Apply interstit radiat compl $417.12 $461.53 $44.41 10.6%

G6011 Radiation treatment delivery $323.67 $292.85 ($30.82) -9.5%

19298 Place breast rad tube/caths $1,069.83 $998.42 ($71.41) -6.7%

31626 Bronchoscopy w/markers $926.97 $858.46 ($68.52) -7.4%

32553 Ins mark thor for rt perq $603.30 $532.59 ($70.71) -11.7%

49411 Ins mark abd/pel for rt perq $558.55 $491.68 ($66.87) -12.0%

57155 Insert uteri tandem/ovoids $438.60 $372.52 ($66.08) -15.1%

Physician in PBDs

• Physicians working in provider-based departments

(excepted and nonexcepted) will continue to bill on

CMS1500 claim form

• Continue to report POS 19 (off-campus outpatient hospital)

code when services are performed at the PBD location

• Physicians will be reimbursed under MPFS facility rates

regardless if work is at an excepted or nonexcepted location

– CMS originally proposed to be paid per non-facility rates,

this was not finalized

– Both PBDs are considered facilities

CMS Recoupment of Overpayments

• Historically when an overpayment by CMS to a provider

occurred, CMS would use the National Provider Identifier

(NPI) to recoup overpayments from Medicare providers and

suppliers

– When not paid in full, referred to Department of Treasury

for further collection and CMS paid a fee for each referral

• Per ACA, CMS or MACs can now collect overpayments

without using the Treasury

• Now collections will be taken from TIN when collection from

NPI directly is unsuccessful

Example for Collecting Overpayment

“For example, a health care system may own a number of hospital

providers and these providers may share the same TIN while having

different NPI or Medicare billing numbers. If one of the hospitals in

this system receives a demand letter for a Medicare overpayment,

then that hospital (Hospital A) will be considered the obligated

provider while its sister hospitals (Hospitals B and C) will be

considered the applicable providers. This authority allows us to

recoup the overpayment of the obligated provider, Hospital A,

against any or all of the applicable providers, Hospitals B and C,

with which it, Hospital A, shares a TIN.”

Notification of Overpayment by CMS

• Notification provided in writing by CMS or Medicare

contractor – both NPI & TIN will not receive letter

• CY 2017 MPFS Final Rule, Medicare Financial

Management Manual, demand letters and MLN Matters

transmittals to provide updates and info on recoupment of

overpayments

• Prior to January 1, 2017 CMS will release information about

new process for recouping overpayments to Medicare

providers about the implementation through Medicare

Learning Network (MLN) or MLN Connects Provider eNews

article(s)

Medicare Advantage Program

• Providers and suppliers must be enrolled in Medicare with “approved

status” in order to render services to enrollees of Medicare Advantage

program

• Approved Status = enrolled and not revoked from Medicare

• Following plans must be enrolled, MA-PD plans, FDRs, PACE, Cost

HMOs or CMPs, demonstration programs, pilot programs, locum

tenens suppliers and incident-to suppliers

• Assists CMS in ensuring providers or suppliers are appropriate to

receive reimbursement

• If an organization or program does not ensure providers & suppliers

comply with requirements, possible sanctions or termination by CMS

Physician Self-Referral Law Updates

• Designated Health Services (DHS) are updated annually

• Four categories of services

– Clinical Laboratory Services;

– Physical Therapy, Occupational Therapy and Outpatient Speech-

Language Pathology Services;

– Radiology and certain other imaging services and

– Radiation Therapy Services and supplies

• No new codes added to Radiation Therapy service and supplies for 2017, 2

codes were removed

– 0019T, extracorporeal shockwave and A9545, I-131 tositumomab

• Full list at, https://www.cms.gov/Medicare/Fraud-and-

Abuse/PhysicianSelfReferral/List_of_Codes.html.

https://www.cms.gov/Medicare/Fraud-and-Abuse/PhysicianSelfReferral/List_of_Codes.html





Office Space & Equipment Rental

• A physician cannot refer a Medicare beneficiary to another

entity with which that physician has a financial relationship

with and that entity cannot bill Medicare (or another

individual, entity or third party payer) or the beneficiary for

the referred services

• Concerns that per-click lease arrangements incentivize

referring physicians to over-refer & over-utilize services to a

lessee through which may or will receive revenue

– CMS proposed and finalized changes for CY 2017

Changes to Per-Click Arrangements

• CMS finalized that rental charges cannot be determined using a

formula based on per-unit of services charges in which the

services provided to patients are referred by the lessor to the

lessee

• Limits set-ups where the “lessor generates the payment from the

lessee through a referral to the lessee for a service to be

provided in the rented office space or using the rented

equipment”

• Arrangements are allowed when the referral for the service

provided in the rented office space or using the rented equipment

was not by the lessor

CY2017 Final Rule MPFS Global Non-Facility Course Compare

Type 2016 Global Course

CF = $35.8043

2017 Global Course

CF = $35.8887

2016 - 2017 Variance

Global Global %

Change

2D 10 fxs $5,099.61 $5,068.92 -$30.69 -1%

3D w/IGRT 33 fxs $17,266.62 $17,284.00 $17.37 0%

3D - w/out IGRT 33 fxs $13,663.64 $13,640.94 -$22.70 0%

IMRT 44 fxs $24,912.99 $25,095.53 $182.54 1%

IMRT 30 fxs $19,489.35 $19,614.25 $124.90 1%

SRS - Linac $5,743.01 $5,506.76 -$236.25 -4%

SBRT Linac 5 Fractions $12,079.65 $11,907.15 -$172.50 -1%

APBI Single Cath $7,214.92 $7,260.64 $45.72 1%

APBI MultiCath $10,065.30 $10,136.05 $70.74 1%

Prostate - HDR $7,212.06 $7,239.11 $27.05 0%

Prostate - LDR $3,157.94 $3,209.17 $51.23 2%

GYN T&O - HDR $5,309.42 $5,128.14 -$181.28 -3%

GYN Cyl 1 Chan HDR $3,535.32 $3,550.11 $14.79 0%

GYN Multi Chan HDR $4,430.78 $4,453.43 $22.65 1%

$-

$100.00

$200.00

$300.00

$400.00

$500.00

$600.00

77280 77280-TC 77280-26 77285 77285-TC 77285-26 77290 77290-TC 77290-26

MPFS Simulation

2016 Final Payment Rate (CF$35.8043) 2017 Final Payment Rate (CF$35.8887)

$-

$100.00

$200.00

$300.00

$400.00

$500.00

$600.00

77332 77332-TC 77332-26 77333 77333-TC 77333-26 77334 77334-TC 77334-26 77338 77338-TC 77338-26

MPFS Treatment Devices


$1.00

$10.00

$100.00

$1,000.00

$10,000.00

MPFS Dosimetry


$-

$20.00

$40.00

$60.00

$80.00

$100.00

$120.00

$140.00

$160.00

$180.00

77300 77300-TC 77300-26 77331 77331-TC 77331-26 77336 77370 77470 77470-TC 77470-26

MPFS MU Calcs, Special Dosimetry, Physics & Special Trmt Procedure


$-

$50.00

$100.00

$150.00

$200.00

$250.00

$300.00

$350.00

$400.00

77401 G6004 G6008 G6012 G6013 G6015 G6016

MPFS Treatment Delivery - EBRT & IMRT


$-

$20.00

$40.00

$60.00

$80.00

$100.00

$120.00

$140.00

77014 77014-TC 77014-26 G6001 G6001-TC G6001-26 G6002 G6002-TC G6002-26 G6017

MPFS Image Guidance


$-

$100.00

$200.00

$300.00

$400.00

$500.00

$600.00

$700.00

77427 77431 77432 77435

MPFS Physician Treatment Management


$-

$50.00

$100.00

$150.00

$200.00

$250.00

$300.00

$350.00

$400.00

77316 77316-TC 77316-26 77317 77317-TC 77317-26 77318 77318-TC 77318-26

Brachytherapy Isodose Planning


$-

$200.00

$400.00

$600.00

$800.00

$1,000.00

$1,200.00

$1,400.00

$1,600.00

77372 77373

MPFS Stereotatic Treatment Delivery - SRS & SBRT


QUALITY PAYMENT PROGRAM

MACRA Final Rule CY 2017

https://www.federalregister.gov/documents/2016/11/04/201

6-25240/medicare-program-merit-based-incentive-

payment-system-and-alternative-payment-model-

incentive-under

Quality Payment Program Final Rule

https://www.federalregister.gov/documents/2016/11/04/2016-25240/medicare-program-merit-based-incentive-payment-system-and-alternative-payment-model-incentive-under






























Final Rule Response to “MACRA”

• Addresses changes to Physician Fee Schedule as signed

into law April 16, 2015 as part of Medicare Access and

CHIP Reauthorization Act of 2015 (MACRA)

• Released October 14, 2016

– Addresses provisions for changes to MPFS per MACRA

– Establishes Merit-based Incentive Payment System

(MIPS)

– Transition away from volume-based to value-based care

A Few Provisions of MACRA

• Repealed the Sustainable Growth Rate (SGR)

– No more proposed significant reductions to conversion factor (CF) each

year

• Established a timeline of payment factors going forward

– 2016 – 2019 CF raised 0.5% each year

– 2020 – 2025 CF update 0%, reimbursement based on MIPS reporting

– 2026 and beyond all about APMs & type of participation

• Qualifying APM = 0.75% update to CF

• Non-qualifying APM = 0.25% update to CF

• Develop Merit-based Incentive Payment System

– Reporting of measures beginning in 2017 for payment adjustments in

2019

Quality Payment Program (QPP)

• Beginning in 2017 reporting measures will determine

payment adjustments (+, - or neutral) in 2019

• QPP rewards values and outcomes through 2 means

– Advanced Alternative Payment Models (Advanced

APMs)

– Merit-based Incentive Payment System (MIPS)

• Only Eligible Clinicians will be able to participate

• Can participate individually or as a group

• Exemptions will apply as well

Who is an Eligible Clinician?

• Physicians

– MD, DO, Dentist, Chiropractor, Podiatrist & Optometrist

• Physician Assistant

• Nurse Practitioner

• Clinical Nurse Specialist

• Certified Registered Nurse Anesthetist

• Group that includes such professionals

• Hospital-based clinician who furnishes 75% or more of covered

pro services under POS 21(inpt) , 22 (opt) or 23 (ER)

Individual or Group

• MIPS eligible clinicians can report as individual or group

• Use TIN/NPI identifier for all 4 categories regardless of how

assessed

• Group reporting assessed as part of single TIN

– Which includes 2 or more eligible clinicians and 1 must

be a MIPS eligible clinician identified by an NPI and

Medicare billing rights are assigned to the TIN

– Data aggregated across the TIN

– Group must maintain status at all times during

performance period

Low-Volume Threshold

• Above threshold = eligible clinician

• Below threshold = exclusion from MIPS program

• Low-volume threshold criteria

– Medicare Part B charges < $30,000 or provides care to 100

or fewer Part B enrolled Medicare beneficiaries for a year

• Low-volume threshold applies to eligible clinicians practicing

under APMs

– If APM is Advanced APM the QA designation is not affected

• Groups can include low-volume threshold EC’s, performance

score applied across TIN, they will not receive any MIPS

payment adjustments

Four Participation Options in QPP

90-Consecutive Days Only

• Pick any 90-consecutive days & report measures

Partial Year

• Minimum 90- consecutive days AND

• Report more than one quality measure, improvement activity OR more than required measures in advancing care information

Full Year

• Report one measure in quality; one activity in improvement activities performance category OR report required measures in advancing care information performance category

Participate in Advanced APM

• 5% Bonus payment in 2019

Any eligible clinician chooses not to report any measures or

activities in 2017, -4% payment adjustment applied to every

claim in 2019!

Performance Categories

• Quality

• Improvement Activities

• Advancing Care Information

• Cost = 0% value in 2017 (transition year) for everyone

Full Participation vs. Threshold

• Full participation means

– Quality category 6 quality measures OR 1 specialty-specific

or subspecialty-specific measure set.

– Advancing Care Information 5 measures reported

– Improvement Activities up to 4 activities are reported

• Meeting Threshold means

– Any eligible clinician reports 1 out of 6 Quality measures,

attests to at least one Improvement Activity or reporting on

required measures in Advancing Care Information will meet

the MIPS threshold of 3 points and receive neutral payment

adjustment

Integrated Performance Categories

• Quality - 2017 category weight = 60%

– Replaces PQRS

– Report up to 6 quality measures, including an outcome

measure, for minimum of 90 consecutive day period

– Groups using Web interface will report 15 quality

measures for the full year

– Groups in APMs will report measures through APM

– General Oncology (19 measures) and Radiation

Oncology (4 specific measures) – Rad Onc under

Oncology per comments received

24b. Radiation Oncology

Title Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk

Prostate Cancer Patients

NQF#/Quality #: 0389/102

Description:

Percentage of patients, regardless of age, with a diagnosis of prostate cancer at

low (or very low) risk of recurrence receiving interstitial prostate brachytherapy, OR

external beam radiotherapy to the prostate, OR radical prostatectomy, OR

cryotherapy who did not have a bone scan performed at any time since diagnosis

of prostate cancer

Measure Steward: Physician Consortium for Performance Improvement Foundation (PCPI)

Measure Type: Process

Measure Domain: Efficiency and Cost Reduction

Data Submission

Method: Registry, EHR


Title Oncology: Medical and Radiation - Pain Intensity Quantified


Description:

Percentage of patient visits, regardless of patient age, with a diagnosis of cancer

currently receiving chemotherapy or radiation therapy in which pain intensity is

quantified

Measure Steward: Physician Consortium for Performance Improvement Foundation (PCPI)


Measure Domain: Person and Caregiver Centered Experience and Outcome

Data Submission

Method: Registry, EHR


Title Oncology: Medical and Radiation – Plan of Care for Pain:


Description:

Percentage of visits for patients, regardless of age, with a diagnosis of cancer

currently receiving chemotherapy or radiation therapy who report having pain

with a documented plan of care to address pain.

Measure

Steward: American Society of Clinical Oncology


Measure Domain: Person and Caregiver Centered Experience and Outcome

Data Submission

Method: Registry


Title Oncology: Radiation Dose Limits to Normal Tissues:


Description:

Percentage of patients, regardless of age, with a diagnosis of breast, rectal,

pancreatic or lung cancer receiving 3D conformal radiation therapy who had

documentation in medical record that radiation dose limits to normal tissues

were established prior to the initiation of a course of 3D conformal radiation for

a minimum of two tissues

Measure Steward: American Society of Clinical Oncology


Measure Domain: Patient Safety

Data Submission

Method: Claims, Registry


• Improvement Activities - 2017 category weight = 15%

– New category

– 93 activities to select from in eight subcategories

• Achieving Health Equity, Behavioral and Mental Health, Beneficiary

Engagement, Care Coordination, Emergency Response & Preparedness,

Expanded Practice Access, Patient Safety & Practice Assessment and

Population Management

– Attest to completing up to 4 improvement activities, for minimum of 90 consecutive

day period

– Groups with fewer than 15 participants, attest completing up to 2 improvement

activities, for minimum of 90 consecutive day period

– Groups in APMs will automatically receive points based on requirements through

participation in the APM and will be assigned full credit for current APMs

– Eligible clinicians in any other APM will automatically earn half credit and can

report more activities to increase score


• Advancing Care Information - 2017 category weight = 25%

– Replaces Meaningful Use

– Fulfill required measures for minimum of 90 consecutive day period

• Security Risk Analysis

• E-Prescribing

• Provide Patient Access

• Send Summary of Care

• Request/Accept Summary of Care

– Choose to submit up to 9 measures for minimum of 90 consecutive day period OR

– If measures do not apply, then no reporting necessary (ex. hospital-based eligible

clinicians)

– The EHR edition used to submit data will determine which set of measures to

select from, link on CMS website at https://qpp.cms.gov/measures/aci can help

determine which edition an eligible clinician uses

https://qpp.cms.gov/measures/aci


• Cost

– Replaces Value-Based Modifier

– No data submission required

– Calculated per adjudicated claims

– Will be counted starting in 2018

TABLE 3: Data Submission Mechanisms for MIPS Eligible Clinicians Reporting Individually as TIN/NPI

Performance Category/Submission

Combinations Accepted Individual Reporting Data submission Mechanisms

Quality Claims, QCDR, Qualified registry, EHR

Cost Administrative claims (no submission required)

Advancing Care Information Attestation, QCDR, Qualified registry, EHR

Improvement Activities Attestation, QCDR, Qualified registry, EHR

TABLE 4: Data Submission Mechanisms for Groups

Performance Category/Submission

Combinations Accepted Group Reporting Data submission Mechanisms

Quality

QCDR, Qualified registry, EHR, CMS Web Interface (groups of 25 or more), CMS-

approved survey vendor for CAHPS for MIPS (must be reported in conjunction with

another data submission mechanism.) and Administrative claims (For all-cause

hospital readmission measure - no submission required)

Cost Administrative claims (no submission required)

Advancing Care Information Attestation, QCDR, Qualified registry, EHR, CMS Web Interface (groups of 25 or more)

Improvement Activities Attestation, QCDR, Qualified registry, EHR, CMS Web Interface (groups of 25 or more)

Potential Payment Adjustments

More information about the Quality Payment Program

available at https://qpp.cms.gov/

Graphic courtesy of CMS.gov

https://qpp.cms.gov/

https://qpp.cms.gov/

Payment Adjustments

• Meet threshold of 3.0 points, no adjustment for CY 2019

– Considered neutral

• Qualifying payments not made in lump sum, applied as an

adjustment factor on a per claim basis

• Applied to any Medicare Part B payments for any items and

services furnished by MIPS eligible clinician

• Years 2019 – 2024 additional bonus payments available

– Only if final score is above additional criteria established

each year

– Additional payment % determined by Secretary

Alternative Payment Models (APMs)

• Transitioning eligible clinicians to APMs is overall goal

– Moves healthcare from volume-based to value-based

• Two types of APMs were finalized

– Advanced APMs

– Other Payer Advanced APMs

• Specific criteria for each to be considered

• New APMs will be available in 2017 and 2018

Advanced APMs Criteria

• To qualify must meet all of the following criteria:

– The APM must require participants to use CEHRT;

– The APM must provide for payment for covered

professional services based on quality measures

comparable to those in the quality performance category

under MIPS and;

– The APM must either require that participating APM

Entities bear risk for monetary losses of a more than

nominal amount under the APM, or be a Medical Home

Model expanded under section 1115A(c) of the Act.

Other Payer Advanced APM Criteria

• Arrangement with a commercial payer or Medicaid & must meet all

criteria

– The payment arrangement must require participants to use

CEHRT;

– The payment arrangement must provide for payment for covered

professional services based on quality measures comparable to

those in the quality performance category under MIPS and;

– The payment arrangement must require participants to either bear

more than nominal financial risk if actual aggregate expenditures

exceed expected aggregate expenditures; or be a Medicaid

Medical Home Model that meets criteria comparable to Medical

Home Models expanded under section 1115A(c) of the Act.

Advanced APMs for CY 2017

• Released by CMS on 10/25/16

– Comprehensive ESRD Care Model (Large Dialysis

Organization (LDO) arrangement)

– Comprehensive ESRD Care Model (non-LDO arrangement)

– Comprehensive Primary Care Plus CPC+

– Medicare Shared Savings Program ACOs - Track 2

– Medicare Shared Savings Program ACOs - Track 3

– Next Generation ACO Model

– Oncology Care Model (two-sided risk arrangement)

Anticipated Advanced APMs for 2018

• Re-opening applications for new practices and payers in CPC+ &

Next Generation ACO Model

• CMS anticipates incentive payments may be available through

following models in 2018

– ACO Track 1+

– New voluntary bundled payment model

– Comprehensive Care for Joint Replacement Payment Model

(Certified Electronic Health Record Technology (CEHRT)

track)

– Advancing Care Coordination through Episode Payment

Models Track 1 (CEHRT track)

Qualifying Participants (QP)

• Eligible clinicians participating in Advanced APMs who have sufficient % of

patients or been paid sufficient amount of payments through APM

• 5% bonus payment beginning 2019 – 2024

• Even services provided in CAHs, RHCs and FQHCs will be counted

• Thresholds will be set to become a QP

– Medicare APM

• Based on Part B payments or # of patients who had services under

Part B

– All Payer Combination Option (uses Medicare APM & Other Payer

Advanced APMs option) – first payment in 2021

• Must participate in Advanced APM under Medicare & submit info to

CMS to determine is thresholds are met

QP Identifier

• Eligible clinicians will be identified by:

– Unique APM participant identifier

– APM entity

– TIN/NPI combinations

• If eligible clinician participates in multiple Advanced APMs

but does not meet threshold in a single one, will be

assessed across combined participation

• CMS will accelerate timeline to let eligible clinicians are

excluded from MIPS prior to need for info submitted

TABLE 14: APM Entity Submission Method for Each MIPS Performance Category

MIPS

Performance

Category

APM Entity Eligible Clinician Submission Method

Quality The APM Entity group submits quality measure data to CMS as required under

the APM.

Cost No data submitted by APM Entity group to MIPS.

Improvement

Activities

No data submitted by APM Entity group to MIPS unless the assigned score at the

MIPS APM level does not represent the maximum improvement activities score,

in which case the APM Entity may report additional improvement activities using a

MIPS data submission mechanism.

Advancing

Care

Information

Shared Savings Program ACO participant TINs submit data using a MIPS data

submission mechanism. Next Generation ACO Model and other MIPS APM

eligible clinicians submit data at either the individual level or at the TIN level using

a MIPS data submission mechanism.

Questions?