2018 MIPS Update: The 10 Changes You Should Know About
In the new 2018 Quality Payment Program (QPP) Final Rule, the Centers for Medicare and Medicaid Services (CMS) has outlined a wide range of changes to its value-based care programs. Are you and your EHR vendor prepared?nn2018 marks the second year of the Merit-Based Incentive Payment System (MIPS), and the requirements are definitely ramping up and posing more of a challenge. However, MIPS is nothing to be too scared of—as long as your practice has the right technology to streamline your MIPS data collection and submission.nnSo what’s specifically changing? In case you don’t have time to read all 1,653 pages of the 2018 QPP Final Rule yourself, here’s an overview:n
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- Payment adjustment increases to +/-5%nCMS is raising the stakes for 2018—if only by 1%. This past year, providers could earn up to a 4% positive or negative adjustment on their Medicare reimbursements (applied in 2019) depending on their performance, but that percentage increases to +/-5% for 2018 (applied in 2020).This means that if your practice bills $1,000,000 in Medicare per year, then your MIPS performance could earn you a $50,000 bonus or penalty in 2020. And since the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) requires MIPS to be budget-neutral, that bonus could increase by an additional adjustment factor if more providers earn a negative adjustment than anticipated.
Low-volume threshold goes upnIn 2018, providers with ≤$90,000 in Part B allowed charges or ≤200 Part B beneficiaries will not be subject to MIPS. Compared to the 2017 MIPS threshold of ≤$30,000 in charges or ≤100 beneficiaries, this is a significant increase. The 2017 threshold already exempted a large proportion of Medicare Part B providers, and this 2018 change will exempt even more.
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- Performance threshold increases to 15nFor the 2017 performance period, providers could avoid the negative payment adjustment in 2019 with a MIPS Composite Performance Score (CPS) of just three points. This could be easily achieved by submitting either one Quality measure, one Improvement Activity (IA) or all Advancing Care Information (ACI) base measures.For the 2018 performance period, you’ll need 15 points or more to avoid the negative adjustment in 2020. While this is a 400% increase, it could still be as simple as completing 2-3 Quality measures, four IAs or all ACI base measures. For practices that are already strong MIPS performers, this minimum threshold change will have little impact. The exceptional performance threshold required for positive adjustments will remain at 70 points.
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- Cost category takes effectnIn its first year, MIPS scored providers on three categories: Quality, ACI and IA, with the Cost category weighted at 0%. Starting in 2018, MIPS adds a 10% weight for the Cost category, which is based on Medicare Part B claim submissions. Because eligible clinicians (ECs) already submit this claims data to CMS, they will not need to send any additional data to report the Cost category.More specifically, Cost scoring is based on the Medicare spending per beneficiary (MSPB) and the total per capita costs for all attributed beneficiaries measure. This could have an enormous impact on the scores of clinicians who frequently prescribe expensive Part B drugs, such as ophthalmologists, rheumatologists and oncologists. We’ll take a closer look at the Cost category in an upcoming blog post, so stay tuned!
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Category weights changenThe Quality category was originally proposed to remain at 60% of the MIPS CPS in 2018, with Cost not factoring in until 2019. However, the 2018 QPP Final Rule introduced Cost this year at 10%, so CMS is decreasing Quality’s weight to 50% to compensate. The ACI and IA categories will remain at 25% and 15%, respectively.
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- Virtual groups participation option introducednWith many small practices concerned about their ability to succeed independently under MACRA, CMS has introduced a virtual groups option that can allow ECs to benefit from group reporting without actually joining a group or selling their practice.To form a virtual group, a solo practitioner or group of 10 or fewer ECs must come together virtually with at least one other solo practitioner or group to participate in MIPS for a year. Group members do not need to be in the same specialty or location. CMS simply requires that they report as a group across all performance categories and meet the same MIPS requirements as non-virtual groupsOnce reporting is complete, all group members will receive the same score and payment adjustment percentage. The idea is that by sharing the reporting burden and combining their strengths, providers may be able to earn higher scores together than individually.The deadline for selecting the 2018 virtual group option is December 31, 2017, so time is running out if you’re interested in participating. To learn more, download CMS’ Virtual Groups Toolkit.
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- Extreme and uncontrollable circumstances exemption addednIn the wake of Hurricanes Harvey, Irma and Maria, CMS has added new hardship exemptions for physicians who cannot meet reporting requirements due to hurricanes, natural disasters or public health emergencies. These will apply to the 2017 performance year as well as 2018, and the application deadline for hardship exceptions will be December 31 each year.How does it work? If affected clinicians don’t submit any data, they will be exempt from penalties. Meanwhile, those who do submit data will be scored on the data they submit, but the categories will be reweighted. If you were impacted in 2017, you may submit an application for reweighting of the ACI category. Even if you don’t submit an ACI application, CMS will automatically exempt you from Quality, Cost and IA for 2017.
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- Small practice bonus institutednIn an effort to further reduce the burden for small practices, CMS will automatically award qualifying practices a bonus of up to 5 points. Practices must have 15 or fewer ECs and submit data on at least one performance category to be eligible.
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- 2014 CEHRT permitted and 2015 CEHRT bonus creatednOriginally, CMS planned to allow 2018 data submission only from 2015 Certified Electronic Health Record Technology (CEHRT). Instead, it has now decided to continue allowing ECs to use 2014 CEHRT—a relief for both vendors and providers. However, CMS is offering a 10% bonus in the ACI category to providers who report with 2015 CEHRT.
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- New ePrescribing and HIE exclusions established starting 2017nTo allay concerns about the difficulty of meeting certain measures involving ePrescribing and health information exchange (HIE), CMS has introduced new exclusions that would allow ECs to claim the exclusion from one or both of those measures and still earn a base score. It’s important to note that these exclusions are being applied to the 2017 performance year as well as 2018.Who’s eligible? To claim the eRx exclusion, a provider or group must write fewer than 100 permissible prescriptions during the reporting period. For the HIE exclusion, they must refer or transition fewer than 100 times during the reporting period.
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Analysis
nWith these new rules, CMS is continuing to ramp up the reporting requirements as planned, building up to full MIPS implementation in 2019. In response to concerns from the healthcare community about the burden of reporting, CMS is also focusing heavily on easing the transition and accommodating real clinical workflows.nnEspecially for small practices, the new QPP rules provide additional flexibility and incentives in a wide variety of areas. As a result, some organizations have actually criticized CMS for not challenging providers enough to substantially improve health outcomes or reduce costs. However, for many physicians and industry associations, this relative leniency comes as a major relief.nnTo learn more and view the full list of calendar year (CY) 2018 MIPS changes, check out CMS’ 2018 QPP Final Rule fact sheet.n
The Bottom Line
nValue-based care is here to stay, but it’s reassuring to see that CMS continues to listen to feedback from the healthcare community. And ultimately, meeting these new MIPS requirements doesn’t have to require an enormous amount of time and resources—it just comes down to whether you have the right tools.nnWith the performance periods for Quality and Cost beginning on January 1st for all MIPS-eligible clinicians, now is a good time to evaluate whether your current EHR will be able to support your MIPS success in 2018. A robust MIPS solution should be able to collect reportable MIPS data during the exam, track and benchmark your CPS in real time and submit your data directly to CMS. Plus, consider augmenting your technology with personal guidance from certified MIPS coaches who are also experts in your EHR system. When you’re equipped with comprehensive MIPS support tools from a proven value-based care performer, you can gain peace of mind while increasing your income.nnWe wish you the best of luck with your MIPS reporting in the new year!nnThis article originally posted by Jayne Collard, CMUP CPHP CMUA, Advisory Services Manager, modmed.com.
Hospitals across Colorado must begin posting self-pay prices Monday for the most common procedures and treatments they offer — a potential first step in bringing more cost transparency to a sector whose pricing ambiguity has frustrated consumers and public officials alike.nnThe move is mandated by Colorado Senate Bill 65, a 2017 measure from Republican Sen. Kevin Lundberg of Berthoud aimed at requiring health-care providers to be able to tell people who are paying bills without the help of insurance what a procedure will cost before they get those services. Medical pricing transparency demans are gaining traction on both state and local levels.nnUnder the new law, health-care facilities such as hospitals must post the self-pay prices for the 50 most used diagnosis-related group codes — the most common reasons for hospitalizations — and the 25 most-used current procedural technology billing codes. Those prices can reflect the most frequent charge over the past 12 months for a service, the highest charge from the lowest half of all the charges for the service or a range that includes the middle 50 percent of all charges for the service. The facility must have performed a service at least 11 times in the past year.nnPhysicians’ offices and other individual health-care providers, meanwhile, are required just to post the prices for their 15 most common procedures.nnThe prices, however, are only those that apply to people who are paying on their own without the help of public or private insurance in a state where less than 7 percent of the population is uninsured. At University of Colorado Hospital in Aurora, the self-pay population represents only 2 percent of the patients coming through its doors and generates just 0.2 percent of its revenue.nnThus, some hospital officials worry that the new requirements will confuse patients even more than they will provide for more transparency. Prices for insured individuals will be vastly different and will depend on the contract each facility has negotiated with each insurer, and even the prices charged to most uninsured individuals can be discounted by hospitals depending on their income level.nn
“I definitely think we’re concerned that this might confuse patients even more,” acknowledged Dan Weaver, senior director of public and media relations for UCHealth. “Because prices are based so much on individual patients, their needs and their insurance plans, I think providing estimates really comes down to the individual patient level.”nnThe newest requirement is not the first attempt at transparency for many hospitals, however. The Colorado Hospital Association adopted a resolution in July saying that hospitals should post facility-fee charges for emergency-department visits and for the most common outpatient diagnostic tests and procedures by the end of 2017. Like SB 65, that sought conspicuous posting of prices online or in the facility’s main office.nnJulie Lonborg, CHA vice president of communications and media relations, said that hospitals across the board are committed to the idea of transparency, even if some are struggling to meet the deadline. That is particularly true of rural medical centers, some of which may not have 50 procedures that they performed at least 11 times in the past 12 months.nn“I think it will help the patients’ relationships with the hospitals, especially the trust part of those,” Lonborg said, referencing growing concern that hospital pricing can be so opaque that some patients question whether there is rationale for it. “I think to the extent that patients couldn’t find that easily, it could have put a chink in the trust relationship.”nnSarah Ellis — a spokeswoman for SCL Health, which operates Saint Joseph Hospital, Lutheran Medical Center and Good Samaritan Medical Center locally — called the efforts to list both the procedure prices and the emergency and outpatient fees “a work in progress” and said the health system hopes to learn more over time about what is most important to customers. Her organization will continue to seek advice from patient advisory groups about any changes that could help to simplify the information.nnChildren’s Hospital Colorado already has the emergency-department fees listed on its website and will post the other required and CHA-encouraged information on Jan. 1, said Heidi Baskfield, vice president of population health and advocacy for the Aurora hospital. However, she, like other system officials, will encourage in the price listings that anyone who has insurance should continue to work through their insurers to understand not just the cost of services but their responsibilities for deductibles and co-pays.nnThis 
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There are 3 new codes for psychiatric collaborative care management services. There is one new code for general behavioral health integration care service. INR monitoring services were also revised deleting 2 codes and creating 2 new codes for INR home and outpatient INR monitoring services.n
Two new flu-vaccine codes were added in 2018. Both CPT codes pertain to quadrivalent vaccinations. There is also a new CPT code for intramuscular Shingles vaccine.n
All of us at Welter Healthcare Partners, we would like to extend our warmest wishes for you this holiday season! As we spend time with family and friends, we reflect on the joyous year we have had due to our clients and those who support and appreciate the work that we do. Our office will operate on a “holiday schedule” as shown below to celebrate the holidays and allow our staff time to spend with their family and friends.n
As most medical practices are aware, not all cases are easy to navigate using the latest medical standards. The information below highlights a complicated surgical case along with the correct CPT and ICD-10 codes. Do you have a complicated surgery case need help with coding? Welter Healthcare Partners would love to help! Please upload the operative note by clicking on the link below. Remember to remove ALL patient protected health information and organization identifiers. Welter Healthcare Partners will not use any medical records submitted in which PHI is not removed and protected.nn