Week 1 – Industry Hot Buttons!nnMACRA: As a result of Congress repealing the historic SGR (Sustainable Growth Rate) reimbursement formula last year, a new pay–for–performance model has been introduced that will directly impact Part B reimbursement. Physician practices across the country will either be incentivized or penalized via reimbursement based on performance and quality care outcomes. The new model, specific to Part B providers, called MIPS (Merit–Based Incentive Payment System) will consolidate all other CMS alternative merit-based incentive programs (PQRS, VBM, EHR incentives) and provide bonus payments to participating providers of eligible APMs (alternative payment models). MIPS helps link fee-for- service payments to quality and value. This epic change became effective on January 1, 2017, so it imperative that your practice is ready to comply with these new requirements.nnModifier 25: Modifier 25 landed itself on both private payer and the OIG hit lists again this year for overuse and blatant misuse leading to millions in overpayments – and everyone wants their money back! Applying Modifier 25 incorrectly can cost your practice tens of thousands of dollars! Understanding this modifier’s appropriate application can be very tricky.nnHere are a few questions to consider before sticking that modifier on your next claim:n
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- Was the patient scheduled to come in for a planned study or procedure only? Did any notable events occur that would affect the service beyond the study or procedure?
- Was the evaluation and management service provided significant and separately identifiable to the procedure or diagnostic study provided at the same encounter?
- Is active management of a significant and separately identifiable illness/ailment with preventive services for additional problems identifiable in the provider’s documentation?
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