Preparing for 2011 –

Where are we and where are we going

Cathie Biga

President/CEO

Cardiovascular Management of Illinois

Agenda

• 2010 in review

• Technical Correction

• 2011 Physician Fee Schedule

• 2011 HOPPS

• Private Payers in 2011

• HCR/ACA – its impact

• Core 2011 concepts: PQRS/eRx….

Legal

Primary Issues• HCR/ACA• Threats to physician ownership/in-office imaging• SGR – will it ever be fixed• IPAB• CMI

Secondary Issues• Key topics – 1) Disclosure requirements for CT, PET, MRI, 2)

PECOS, 3) POS/DOS, 4) Timely filing • 2012 Accreditation of labs and 2010 IAC changes• Meaningful use – stretch or a barrier?

Regulatory

• PFS 2011– 2nd year of PPIS implementation– Bundling continues– Rebase for MEI– RUC focus

• HOPPS 2011– Reductions beginning?

• Quality focus continues to grow• Ongoing scrutiny of imaging and IOE• EP becomes its own specialty 4/4/11

– ENROLLMENT NEEDED

Economic• Gap in technical

– Bundling of nucs ’10

– Bundling of caths ’11– Massive PV bundling

• RAC’s, MACs, and other attacks

• Revenue wherever you can find it– Clinical integration– PQRI

– eRx– Meaningful use

• Operational efficiencies

• New product lines

Technical Correction

• What is it

• What do we do

• What have people done

• Current status

What is the real story

• In May of 2010 the updated files also contained updates to RVU units. This has a range of .60 refunds to $50 –$60 increases for some services

CPT Short Description January 2010 RVU May Updated RVU 78452 Rest stress SPECT 10.52 12.19 92980 Coronary Stent 22.69 24.34 93510-26 Left cath in hospital 6.52 7.00 93620 Comprehensive EP Study 17.56 18.81 Decreases Will there be refunds/recoups? 99214 Established pt level 4 office visit 2.73 2.71 93295 ICD remote per 90 days 2.28 1.94 93279-26 PM program eval – single, MD only .98 .88

Refund Request

Technical Correction

• $2M just appropriated for re-filing

• How to handle both the upside….and the downside

• Patient responsibility• Secondary's• You have to love it…

2011 Fee Schedule

• Be sure you have downloaded the one with the $33.97 CF

• Let’s walk through the key elements and lo lights

Resource Based Relative Value ScalePayment =

RVU = Relative Value Unit

GPCI = Geographic Practice Cost Indices

{(RVU work x GPCI work) + (RVU practice expense x GPCI practice expense) + (RVU malpractice x GPCI malpractice)}

conversion factor x BNX

Medicare formula

SGR…..

• SGR …. • Rollercoaster throughout 2011• 13 month “fix”

– That only cost $19 BILLION– No increase for physicians

• After the May technical correction the CF was $36.8729

• Sunset – Dec 1, 2010 (was to be a 23.6% hit)• Sunset – Jan. 1, 2011 – 12 month extension• 2011: Conversion Factor = $33.9764

MEI …impact

• CMS is rebasing and revising the MEI to use a 2006 base year in place of a 2000 base year. – This update to the MEI is the first time it has

been rebased and revised since 2004. • For practices with high technical this will

result in an increase• Total RVU’s attributed to work will see a

decrease• Bottom line – mitigated a bit of the PPIS hit

– Resulted in a major CF change

Why do my fees keep changing RVU changes

• This is the last year of a 4 yr phase in on how PE are determined – we are DONE with this

• This is the 2nd yr (of a 4 yr plan) due to the PPIS

• This is the 1st time MEI has been re-based• The RUC keeps messing with us

– Bundling– Revaluing

Other key factors of2011 Fee schedule

• Financial Disclosure letter and sites– MRI, CT, PET– Time of referral– 5 suppliers within 25 miles– Document compliance

• EU rate – 75% • Multiple procedure reduction

– Affects technical component– 25% increases to 50%

MEI…PPIS…CF….Just tell me what it means

Treadmill

Hopps

• Echo payment reduced – 13.5%

• PET reduced

• Supervision re-defined– Hospital outpt on campus– Hospital outpt off campus

Cardiac Nuclear StudyMedicare Reimbursement - Technical Component

2006 - 2010 CPT vs. APC

$568.63

$504.50$484.61

$423.90

$264.64

$552.70$560.93

$724.19$742.68 $743.61

$200.00

$300.00

$400.00

$500.00

$600.00

$700.00

$800.00

2006 2007 2008 2009 2010

Reim

burs

emnt

APC

CPT

CARDIOVASCULAR MANAGEMENT OF ILLINOISHOPPS '10 - '11AUGUST 10, 2010

Local 15National HOPPS 2010

APC CPT Description 2010 2011 Change MPFS377 78452 Nuclear 775.09$ 768.38$ -0.9% 386.32$ 99 93005 EKG 26.56$ 27.29$ 2.7% 11.76$

100 93017 Stress 176.17$ 179.55$ 1.9% 56.46$ 269 93306 Echo 450.97$ 389.25$ -13.7% 179.38$ 269 93350 S/E 450.97$ 389.25$ -13.7% 133.52$ 270 93351 S/E 596.04$ 559.41$ -6.1% 156.85$

HOPPS changes

Private payor shenanigans

• Highmark…..– Substitute echo for nuc

• United pre-notification

• Humana pre-notification

• Report cards

HCR aka ACA

• Grandfathered and non-grandfathered plans• Coverage• Lifetime limits• Equipment Utilization: The ACA overrules the

fee schedule and will lock this rate at 75%• House energy and commerce – J.Pitts

• my first legislative priority will be wholesale repeal of the health law, which will pass the House, I'm sure, but realistically won't get past the Senate or the president.

• ACA law requires that PCMHs be exclusively primary physician based, how do we ensure specialty based PCMH models can be authorized

Integration

• Drivers– HCR– MedPac and imaging scrutiny– Payment reform mandates– HOPPS vs PFS

• Is it here to stay?????

ACC’s survey

Integrate with hospital….Or

Other practices

Integrated Practices

ACO’s…..

• Rules due out in Jan• ACA attributes patients to ACOs (by virtue of

the doctors and hospitals they currently use) ---patients do not enroll in them. – This is confusing, because if patients do not want to

be in an ACO and instead stay with their doctor who chooses not to participate, they may. But if their doctor is in, so is the patient. This issue may need to be amended somehow

AUC…..where is it going

• Midei case in Baltimore– ACE from SCAI (accreditation for cardiovascular excellence)

• JAMA article on ICD

• FOCUS – nuclear

• Lab accreditation– MIPPA– IAC – focus on use of AUC

Quality …where is it going?

• Recent CMS report– 3 demo projects

• Hospital Quality Incentive Demonstration (HQID)

• the Physician Group Practice (PGP) • 500 small and solo physician practices

participating in the Medicare Care Management Performance (MCMP

– http://www.cms.hhs.gov/DemoProjectsEvalRpts/MD/list.asp.

Physician Compare

• Public reporting of data

• Starts 1/1/13

• Mandated by ACA

• Physicians need to be able to update their contact info

• Comment period is now

Few more….

• Sunshine Act– 2012– Anything over $10 will be reported

• PECOS– CMS is working “diligently”– Edit not turned on for referring MD– NO DATE has been announced

• Red Flag – finally gone

What is this “new” MOC

• MOC = Maintenance of certification• Additional .5% in PQRS payments if

enrolled in MOC• Must submit PQRS data for 12 months,

participate in MOC, and complete MOC practice assessment– FOCUS and CPIP

PQRS aka PQRI

• PVRP was initial program in 2006

• PQRI - 7/1/07 – 1.5% incentive payment

• 2008 – Few structural changes

• 2009 and 2010 - 2% incentive payment

• Yes you can do this + Meaningful use

• 2011 – Physician Quality Reporting System

• 194 measures

PQRS ResourcesA Guide for Understanding the 2011 Physician Quality

Reporting System (PQRS) Incentive Payment

• www.cms.gov/pqrs • https://www.cms.gov/PQRI/

15_MeasuresCodes.asp#TopOfPage• http://www.cms.hhs.gov/

MedicareProviderSupEnroll• http://www.cms.hhs.gov/IACS • https://www.cms.gov/PQRI/

30_EducationalResources.asp#TopOfPage

Key Changes• Penalties start in 2015• 2011 – 1% payment• 2012 – 2014 - 0.5% payment• Reporting sample reduced from 80% to

50% for claims ONLY– Registry still must meet 80% on 3 measures

• Registries no longer can report on non-Medicare FFS

• Measures with 0% will not be counted• New group reporting option <200

– 26 measures

Changes to Structure and Function

• In response to ACA

• Penalty: 1.5% in 2015 & 2.0% after

• Timely feedback

• Interim reports

• Informal appeal process

• Physician Compare Website– Reports 2012 PQRS

• Integration with MU

Measures

• 170 measures continue (24 new)

• 45 registry measures continue– 11 new registry only

• 14 Measure Groups

• EHR current 10 + 10 new

PQRI 2011

No ChangesNo Changes#6 – CAD on Antiplatelet#7 – CAD prior MI on BB#47 – Advance Care Plan#124 – Use of EMR#201 - IVD & BP Control#202 - IVD & Lipid Profile#203 – IVD & LDL

New#128 – BMI Screening &

Follow Up#226 –Tobacco Screening &

Cessation#235 – HTN Plan of Care

Changes#5 – HF on ACE/ARB#8 – HF on BB

(remove Cardiomyopathy codes)

#114 – Smoking Screening#115 – Smoking Cessation

(retired)

#118 – CAD on ACE/ARB & DM and/or LVSD(remove Pregnancy Diabetes codes)

No changes for 2011 Changes for 2011

#6 - CAD #5 –HF c ACE/ARB

#7-CAD c BB #8 – HF c BB

#47 – ACP #118 – CAD c…

#201 – IVD/BP #124 - EHR

#202 – IVD/lipid #128 - BMI

#203 – IVD/LDL #197 –CAD c lipid

Retired for 2011

#114 - screening

#115 -cessation

Other non cardiac

#136

#139

#174

Summary 2011 changes

eRx for 2011

• Can NOT do in addition to MU• You can do eRx + PQRI• 1% Incentive payment• Need to do 25 instances • 2011 report for entire year• Penalties start in 2012

BUT

****IMPORTANT****

• See pgs 1305 to 1307• MUST have an approved system• 10 instances per provider from Jan1 –

June 30, 2011– Must do even with MU– Must do via CLAIMS– Submit the G code to prevent penalty

• Not only does 2011eRx determine 2012...but  it also locks you in for the penalty!

THE Penalty

• You can NOT use EHR or registries to submit– Yes you can receive incentive money……..and still

be penalized• Penalties will be NPI specific• CMS needs info by 12/21/11• Are they reaching beyond their legal scope?

Note the 2013 penalty

Are there any exceptions…• Provider does not have at least 100 cases containing an encounter

code in the measure denominator• Provider does not meet the 10% denominator threshold• For the 2012 eRx payment adjustment, the following

circumstances would constitute a hardship: – The eligible professional practices in rural area with limited high-

speed internet access, or– The eligible professional practices in an area with limited available

pharmacies for electronic prescribing

• G-codes have been created to address two hardship circumstances (G8642 and G8643)

• To request a hardship exemption for 2012 payment adjustment: An eligible professional must report the appropriate G-code on at least 1 claim prior to June 30, 2011

eRx ComparisoneRx Incentive 2011• Attached to an E&M code • Use Code G8553• Must submit 25 eRx Medicare

patients to get 1% incentive• Reported on claims or Registry

eRx Penalty 2012 & 2013• Attached to an E&M code • Use Code G8553• Must submit 10 eRx Medicare

patients between January and June 30, 2011 to avoid 1% adjustment in 2012

– Report on Claims only• Must submit 25 eRx Medicare

patients between January and December 31, 2011 to avoid 1.5% adjustment in 2013

– Report on Claims or Registry

eRx Meaningful Use• Does not tie to an E&M code • Doesn’t use G codes• Must have more than 40% of

all permissible prescriptions transmitted electronically

• Tracks faxed, printed or e-prescribed prescriptions

• Excludes Controlled Substances

• Applies to all patients, not specific to Medicare

Qualified eRx system is…• Must do ALL of the following

– Generate an Active medication list• Incorporates e data from pharmacies and pharmacy

benefit managers• Select meds, print prescriptions, transfer

electronically, and conduct ALL alerts:– Provide info on lower cost alternatives

• Tiered formulary info is sufficient in 2010– Provide info on formulary or tiered formulary medications, pt.

eligibility, and authorization requirements received electronically from pt’s drug plan

Lessons learned

• Remember the 10% rule

• Don’t forget mid levels

• How penalty will be applied…

www.cms.gov/erxincentive

Is it worth it???

• Clinical Integration $134,940

• Clinical Integration $272,114

• PQRI @ 2% $219,175

• PQRI @ 2% $167,915

• eRx @ 2% $174,473

• eRx @ 2% $168,652

$1,137,269Personally I think that is REAL money

Meaningful Use25 Objectives and Measures

– 15 Core Mandatory Measures– 10 Menu Measures (Must meet 5 out of 10)– 6 Total Clinical Quality Measures

• 3 Core • 3 out of 38 from Menu set

Reporting – 8 Measures reported through Attestation– 1 Measure reported with Numerator and Denominator and Exclusion

through Attestation (Clinical Quality Measures)– 16 Measures reported through Numerator and Denominator

Reporting Period• First year of demonstration: Any continuous 90-day period within

the payment year in which you successfully demonstrate Meaningful Use

• Second payment year and beyond: The EHR reporting period will mean the entire payment year

Meaningful Use = Core Measures1. CPOE = 30%2. Drug-Drug and Drug-Allergy Interaction Checks3. Up-to-Date Active Diagnoses List = 80%4. eRx = 40%5. Active Medication List = 80%6. Active Allergy List = 80%7. Demographics (Race, Ethnicity, Preferred Language, DOB,

Gender) = 50%8. Vital Signs (Height, Weight, BP) = 50%9. Smoking Status = 50%10. Clinical Quality Measures11. One Clinical Decision Support Rule12. Electronic Copy of Health Information upon Request within

3 business days (Patients only) = 50%13. Clinical Summaries each OV = 50%14. One Test to Electronically Exchange Clinical Information15. Security Risk Analysis

Meaningful Use = Menu Measures1. Drug Formulary Checks ***2. Lab Results = 40%3. Patient Report with Specific Condition ***4. Reminders for Preventive/Follow Up Care

= 20%***5. Electronic Access to Health Information

within 4 business days = 10%6. Patient Education = 10% ***7. Medication Reconciliation = 50%8. Summary Care Record with Transition of

Care = 50%9. Immunization Registry ***10. Public Health Surveillance

Getting Ready

• Smoking Changes– Risk Factor– Cessation Pick list

Measure 7 - Demographics

• Need all fields filled in– DOB– Gender– Preferred Language– Race– Ethnicity

• Goal = 50% or betterA = 44%C = 38%H = 29%

Reports

Report Cards

THANK YOU

QUESTIONS???