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11/8/2017The SGR (Sustainable Growth Rate) RealityMACRA and MIPS:Strategies for SuccessMichael Granovsky MD, CPC, FACEPPresident, LogixHealthHMMM How Does MACRA Make TheSGR Go Away?The Big Picture: CMS Payment EvolutionBalanced Budget Act of 1997MACRA 35.75471998 GDP6.1%2008/2009GDP 0.5 28.174741
11/8/2017Is MIPS a Big Deal?Economic Impact of MIPSPayment Timeline of MACRA/MIPSYearPercentage40k ED60k ED80k ED20194% 48,000 72,000 96,00020205% 60,000 90,000 120,00020217% 84,000 126,000 168,0002022 9% 108,000 162,000 216,0005MIPS Participation: Physician & NP/PA20172017/2018 MIPS Provider Participation2018 You’re excludedif you or yourgroup has 90,000 in PartB allowedcharges or 200Part Bbeneficiaries7While more than half of clinicians (roughly 780,000)billing under the Medicare PFS will be excluded fromMIPS, most EM physicians will be subject to MIPS2017 CMS MIPS/APMs Final Rule Table 582018 Final Rule estimates 36,522 MIPS eligible clinicians (54.1%)82
11/8/2017NPI Look-Up ToolMIPS StructureBlends Together 3 CMS programs: PQRS, Value Modifier,and EHR Meaningful UseFour Components of the MIPS Composite 2018 Advancing Care Information (25%)Hospital Based Exemption Detail2017/2018 Cost CategoryFinal Rule WeightingSection 1848(a)(7)(D) of the Act exempts hospital-based EPsfrom the meaningful use payment adjustment.“We believe that a transition period would beappropriate; we are lowering the weight of the costperformance category for the first and second MIPSpayment years. We are finalizing a weighting of 0% forthe transition year and 10 percent for the second MIPSpayment year.”“We defined a hospital-based EP as furnishing 75% of his/herservices in sites of service identified as an inpatient hospitalor emergency room in the year preceding the paymentyear, Claims with Place of Service Codes 21 (inpatienthospital), 22 (outpatient hospital), or 23 (emergencydepartment) are considered hospital-based.”CMS MACRA Final Rule p.630/2398Reweighting to Quality11123
11/8/20172017/2018 ED MIPS Scoring Simplified20172017/2018 Data Submission Mechanisms2018QualityClaimsQCDRQualified RegistryEHRResource UseAdministrative Claims(no submission required)ED MIPSQualityCostImp. Act.75%10%15%Medicare Spending perBeneficiary (MSPB) andtotal per capita costAdvancing Care Information AttestationQCDRQualified RegistryEHRImprovement ActivitiesAttestationQCDRQualified RegistryEHR13MIPS: Quality Reporting2017/2018 Data Completeness Threshold2017/2018 MIPS: Quality Report up to 6 quality measures, including oneoutcome/high priority measure, for a minimum of 90days (or a specialty measure set)‒CategoryClaimsQualifiedRegistryHigh priority measures: Outcome (beyond the required outcomemeasure) Appropriate use Efficiency Care coordination Patient safety Patient experienceGroups may use facility-basedmeasurement and elect theirhospital value base purchasingscore in istry(QCDR)CertifiedEHRTechnology50% ofMedicarePart Bpatients50% ofALLpatients50% ofALLpatients50% ofALLpatients60% ofMedicarePart Bpatients60% ofALLpatients60% ofALLpatients60% ofALLpatients4
11/8/2017MIPS: QualityClasses of Measures for 2017/2018Class I: Measures scored basedon performanceClass 2: Measures assigned aflat score of 3 points for 2017 The measure has abenchmark Do not have abenchmark Has at least 20 cases Does not have 20 cases Meets the datacompleteness standard2017 50%; 2018 60% Does not meet datacompleteness criteria Receive 3 to 10 points basedon performance comparedto the benchmark(2017/2018)‒2017 Crafting A SolutionFor The 85% QualityReporting2018 flat score 1 point2017 Emergency MedicineSpecialty Measure SetMeasure#2017 The Emergency Measure Set RealityEM CPTCodesClaimsRegistry/QCDRNOXXAppropriate Testing for Children with PharyngitisXNOXAcute Otitis Externa (AOE): Topical TherapyXXXMeasure Title47Care Plan (NOTE: POS 23 Excluded)669193CEHRTXAcute Otitis Externa (AOE): Systemic Abx. Avoidance of Inappropriate UseXXXAvoidance of Antibiotic Treatment in Adults with Acute Bronchitis (18-64)XNOX130Documentation & Attestation of ALL RX & OTC MedicationsNOXXX226Preventive Care and Screening: Tobacco Use: Screening and CessationNOXXX254Ultrasound Determination of Pregnancy Location for Pregnant Patients withAbdominal PainXXX255Rhogham for Rh-Negative Pregnant Women at Risk of Fetal Blood ExposureXXX317Preventive Care and Screening: Screening for High Blood Pressure andFollow-up DocumentedXXX402Tobacco Use and Help with Quitting Among AdolescentsEmergency Medicine: Emergency Department Utilization of CT for Minor BluntHead Trauma for Patients Aged 18 Years and Older416Emergency Medicine: Emergency Department Utilization of CT for Minor BluntHead Trauma for Patients Aged 2 through 17 Years431Preventive Care and Screening: Unhealthy Alcohol Use: Screening & BriefCounseling374Closing the Referral Loop: Receipt of Specialist Report [EHR only measure]NONOXXXNOXXXXXNONOXMeasures in the measures set‒116415* Measures in the Emergency Medicine set WITH 9928Xcodes, but NOT‒Xwithout ED codes#47 Care Plan, #130 Documentation of medications,#226 Tobacco cessation screening, #374 Closing thereferral loop, #402 Tobacco use adolescents, #431Alcohol abuse screeningreportable via CLAIMS#66 Testing for children what pharyngitis, #116Avoidance of antibiotic use for adults with bronchitis205
11/8/2017Measures in the Emergency Medicine set WITH9928X codes AND reportable via CLAIMS N 20 at the NPI level if reporting via claims #91- Otitis externa topical therapy #93- Otitis externa avoiding PO Abx # 254- US determination of pregnancy location w/abdominal pain #255- Rhog. for RH- at risk for fetal blood exposure #416- Head CT for minor blunt trauma 2-17 years old #415- Head CT for minor blunt trauma 18 years old # 317- Screening for hypertensionACEP Discussion with CMS ACEP/CMS phoneconference reviewingED measure set March 8th follow-upletter explaining scoringimplications MAV type clinical clustervalidation requestedACEP Letter to CMS Requesting MAV like Clinical Cluster21Scoring The Quality Measures 22Benchmarking Example – Measure #317CMS has released performance benchmarks for eachmeasure on the qpp Not all measures will have a benchmark‒If measure can be reliably scored againstbenchmark, clinician can get 3-10 points‒If no benchmark, clinician only gets 3 points‒Get 3 points for just reporting some data23246
11/8/2017MIPS Quality Measure Scoring DetailAn Epidemic of Pregnant Medicare Patients? Draft and final CMSClinical Cluster forEmergency Care Only had pregnancyrelated measures#254/#255 June 20th letter to CMS25Claims Based Clusters26Anyone with Anything at Anytime2016287
11/8/2017Eligible Measure Applicability (EMA)The #317 Conundrum The EMA process only used with claims or qualifiedregistry data submissions. Not with Qualified ClinicalData Registry (QCDR) and Certified ElectronicHealth Record Technology (CEHRT) Step 1: Clinical Relation Test sees if there are moreclinically related quality measures based on the one tofive quality measures you submitted. OR Clinical Relation and Outcome/High Priority Test ifnone of the six or more quality measures you submittedare an outcome or high priority measure, this test sees ifany are clinically related to an outcome or high priority.130- no 9928x codes226- no 9928x codes (but yes 99406/07)134- no 9928x codes2930CMS Response If a provider submits measure 317 along with CPT codes 9928199285, does the clinical relation test require the provider reportmeasures 130 and 226 in this General Care cluster, eventhough these measures cannot be scored for that provider asthey have no applicable denominator? For claims EMA, if a submitted measure is clinically related toother measures, the eligible clinician would be analyzed bythe Minimum Threshold Test to determine if there were 20denominator eligible encounters. Analysis performed wouldverify the CPT codes billed and identify if the eligible clinicianwould not be eligible to report 130 and 226 because of thelack of denominator-eligible patients.31The Other 15%Improvement Activities328
11/8/20172017/2018 Improvement Activities (15%) 2017 92 activities across 8categories Activity worth 20 pts. (High weight)or 10 pts (Medium weight) Want to score 40 points Activity must be implemented atleast 90 days Need to specifically documentactivities for audit purposes2017 /2018 Per CMS: The tivities2018- 21 new Improvement Activities (CDC Training Courses Opioid and Abx)2018- Need a path to 15 MIPS points to avoid a penalty-Improvement Activities-Data Completion for 6 Quality Measures3334MIPS Next Steps 2017- CMS cluster guidance – preform some qualityreporting 2017- Should have already initiated ImprovementActivities 2018 MACRA Rule:‒Contact InformationMichael Granovsky, MD, CPC, FACEPPresident, LogixHealthThresholds to avoid penalties raised com781.280.1575 Need 15 points 2019 likely allows facility Value Based PurchasingHospital Score to apply to ED docs who opt inStay Tuned!359
11/8/2017Evolution of Quality ProgramsVoluntaryReporting5.0%Pay for PerformancePay for Reporting4.0%4.0%3.0%2.0%2.0%Penalty / BonusEducational 20170.5%-1.5%-2.0%-3.0%-2.0% -2.0%-4.0%-4.0%-5.0%2006Who Is Required to Participate in MIPS? Medicare physicians‒Doctor of Medicine‒Doctor of Osteopathy‒Doctor of Podiatric MedicineFT, PT, moonlighters‒Physician Assistant**‒Nurse Practitioner **‒Clinical Nurse Specialist‒Certified Registered Nurse Anesthetist‒Certified Nurse Midwife‒Clinical Social WorkerReporting issue if noqualifying RS Legislative Forces and Background (PVRP) Physician Voluntary Reporting Program Tax Relief and Health Care Act of 2006 (TRHCA) 2008 Congressional bill (MIPPA) made PQRI programpermanent- transitioned to current PQRS Physician QualityReporting System Affordable Care Act mandated- Value based modifier program(VBM) 2015 Medicare Access and CHIP Reauthorization Act of(MACRA) created Merit-based Incentive Payment System(MIPS)‒‒Practitioners2007Pilot program for 20062007 created Physician Quality Reporting Initiative (PQRI)10
11/8/2017Medicare Cost Methodology Medicare Cost MethodologyTotal Per Capita Costs for All Beneficiaries, evaluates allMedicare Part A and B costs associated with anybeneficiary over a year. Relies on a 2-step attributionmethodology triggered by the group that provides theplurality of primary care services (as measured byallowable charges). A MIPS eligible clinician must havea minimum or 20 cases attributed to them to be scored.CMS will apply a specialty adjustment to this measuresince it found, when implementing this measure as partof the VM, that there were widely divergent costsamong patients treated by various specialties. Medicare Spending per Beneficiary, evaluates Part Aand B costs spanning an episode defined as 3 days priorand 30 days after an inpatient hospitalization.Beneficiaries are attributed to the group that providedthe plurality of all Part B services during the inpatient stay(as measured by allowable charges) so it’s not justlimited to primary care services. When CMS evaluatesthe inpatient stay for attribution purposes, it looks at PartB services provided in an acute care setting that wereprovided the same day as the admission until the day ofdischarge so this could include ED services providedprior to the patient being admitted.41Medicare Cost Methodology Medicare Spending per Beneficiary (cont.) If an EDclinician or TIN contributed to the plurality of a patient’spart B costs during that inpatient stay, they would beheld accountable for the entire cost of the MSPBepisode (which is 3 days prior until 30 days post hospitalstay). A MIPS eligible clinician must have a minimum or35 cases attributed to them to be scored. Note that CMSwill NOT adjust the MSPB measure by specialty since it isalready adjusted on the basis of the index admissiondiagnosis-related groups (DRGs), which is likely to differbased on the specialty of the clinician attributed to themeasure. CMS believes this adjustment adequatelydifferentiates patient populations by different specialties.422017 Scoring- CMS Simplicity434411
11/8/2017Contact InformationMichael Granovsky, MD, CPC, FACEPPresident, th.com781.280.157512
Aug 17, 2017 · 226- no 9928x codes (but yes 99406/07) 134- no 9928x codes CMS Response If a provider submits measure 317 along with CPT codes 99281-99285, does the clinical relation test require the provider report measures 130 and 226 in this General Care cluster, even th
