The revenue cycle
On January 1, 2017, CMS will implement the Quality Payment Program of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). After months of talking to physicians across the country, with an emphasis on small and rural non-hospital-based physicians, CMS released the final rule on October 14, 2016 (Livingston, Shelby, 2016) (Health and Human Services, 2016). To read the 2015 legislation, visit Congress.gov. For the final rule, visit cms.gov. Additional resources are listed at the end of this blog.
To summarize, MACRA replaces three other CMS quality data programs (PQRS, Meaningful Use, and Value-Based Modifier) with a single Quality Payment Program. In addition, MACRA eliminates the Sustainable Growth Rate formula (SGR) by replacing the 1997 penalty-based system which would have cut fees for all services across the board every year, if not blocked by Congress in an annual nail-biting ritual (Stuart Guterman, 2015) that came to be known as “doc fix”. According to CMS, 2015 would have seen a 21% cut in Medicare payments to clinicians if the doc fix had not been passed (Center for Medicaid & Medicare Services). Instead, a small annual inflation-based fee increase will be coupled with incentives and penalties based on performance.
The new Quality Payment Program has two tracks. Medicare Part B providers may be in one, both, or neither. The QPP tracks are:
MIPS performance scores are based on the following general areas:
To get started exploring the measures selected in each category for the Quality Payment Program, visit the new Medicare QPP website.
Under MACRA, Advanced Alternative Payment Models refer to specific payment models run by CMS which satisfy certain additional requirements. Under APMs, the clinic or physician bears some financial risk. MACRA provides incentive payments for participation in APMs. For more details on which APMs are incentivized under MACRA, see SA Ignite’s FAQ.
Impact of EHR Use on Your Score
The Advancing Care Information component of the QPP, which deals with health IT, encompasses 25% of your total MIPS performance score. However, it is only 25%. By focusing on your top six Quality Measures now, which account for 50% of your score, you can move your practice a long way towards being ready when reporting starts in 2017. But get ready. By 2018, the use of certified EHR technology will be mandatory. You can search the official Certified Health IT Product List to see whether your EHR or one you are considering, is certified: CHPL Search.
Support for Small Practices
CMS projects that more small practices will participate in the Quality Payment Program than in the older programs, because, they claim, there will be a “reduced reporting burden, increasing usability of technology, and stepped-up technical assistance” (Center for Medicaid & Medicare Services, 2016). The law provides $20 million each year for five years to provide training and education to Medicare providers in practices of 15 or fewer clinicians or those working in underserved areas. This funding is intended to provide support across the board, including the area of health IT.
Alternatives to Participation in MACRA
Small and individual practices do have options to participating in MACRA, however these options involve completely changing how your practice is structured:
Government interference and healthcare “reforms” will not be coming to an end. The rate of new regulation and its impact on small practices continues to grow. Out of frustration, more and more physicians opt to become employed and give up trying to run their own independent practices in this environment. Every time this happens, the patients suffer. More and more independent practices are turning to alternative payment models, and finding greater satisfaction in their work by opting out of a system that they are powerless to change.
Additional Resources on MACRA
Estimate the financial impact of MIPS with a free calculator
Quality Payment Program Fact Sheet
Where to Find Help
Small Practice Fact Sheet
Comprehensive List of APMs
Learn More About Improvement Activities and APMs
Center for Medicaid & Medicare Services. (2016, October 14). QPP_Small_Practice.pdf. Retrieved from qpp.cms.gov: https://qpp.cms.gov/docs/QPP_Small_Practice.pdf
Center for Medicaid & Medicare Services. (n.d.). The Merit-based Incentive Payment System: MIPS Scoring Methodology Overview. Retrieved from cms.gov: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MIPS-Scoring-Methodology-slide-deck.pdf
Health and Human Services. (2016, October 14). HHS finalizes streamlined Medicare payment system that rewards clinicians for quality patient care. Retrieved from https://www.hhs.gov/about/news/2016/10/14/hhs-finalizes-streamlined-medicare-payment-system-rewards-clinicians-quality-patient-care.html
Livingston, Shelby. (2016, October 13). MACRA final rule is set to drop, maybe even this week. Modern Healthcare. Retrieved from http://www.modernhealthcare.com/article/20161013/NEWS/161019948
SA Ignite. (2016, April 27). 10 FAQS About the Merit-Based Incentive Payment System (MIPS). Retrieved from http://www.saignite.com/resources/faq-about-merit-based-incentive-payment-mips
Stuart Guterman. (2015, April 15). With SGR Repeal, Now We Can Proceed with Medicare Payment Reform. To The Point. Retrieved from http://www.commonwealthfund.org/publications/blog/2015/apr/repealing-the-sgr
Did you know that CMS considers medical necessity the primary criterion for payment? When it comes to problem-based Evaluation & Management services, proper documentation of the History of Present Illness is absolutely crucial in establishing medical necessity. And it turns out that HPI documentation is frequently deficient, lowering reimbursement and opening providers up to penalties and repayment.
Correctly documenting HPI is not difficult. There are two approaches, depending on the patient's presenting problem:
Below, you'll find a list of the CMS approved HPI descriptors with examples of each. As a mnemonic, you can clip out the list and store it on your smartphone, or print it out and tape it in a handy location.
HPI DESCRIPTORS (with examples)
Documenting at least four of these descriptors at every patient visit will result in a more robust history, will protect you during audits, and will guarantee that something as minor as a deficient HPI does not interfere with your reimbursement.
Effective Oct. 1, 2016, the 2017 ICD-10 CM edits are in force! ICD hasn't been updated for three years, so there are a LOT of new, revised and deleted codes. In this blog I'll point out the major changes to the codes used in gynecology and obstetrics. I'll also provide you with a link to just those changes, as well as a link to the entire set of updates for 2017. But first, I'd like to review some of the main changes to OB coding that came about with the switch to ICD 10 last year.
CODING OBSTETRICS IN ICD-10
ICD 10's obstetric codes are found in Chapter 15 and begin with the letter "O". A few codes are also found in Chapter 21, the "Z" codes ("V" codes in ICD 9). Chapter 21 covers "Factors influencing health status and contact with health services". In addition to changing chapters and alphanumeric designations, ICD 10 added codes to capture the trimester, the weeks of pregnancy, and the fetus affected in multiple gestations, for the first time in United States coding.
Trimesters are counted from the first day of the last menstrual period. They are defined as follows:
ICD 10 further instructs to "Use additional code from category Z3A, Weeks of gestation, to identify the specific week of the pregnancy". Thus, every encounter in the prenatal record must include a code from Z3A._. The Z3A._ code follows the O00 - O9A codes for obstetric complications.
Another major change to OB coding in ICD 10 is the use of a 7th character extension to denote the fetus affected by the mother's condition, when there are multiple gestations. This extension is required for code categories O31, O32, O33.3 to O33.7, O35, O36, O40, O41, O60.1 to O60.2, O64, and O69. If the fetus cannot be determined, the number 0 is used in the 7th position. Remember that when adding a 7th character extension, the letter "X" is used as a placeholder to get you out to 7 characters. Example: O31.21X2 Continuing pregnancy after intrauterine death of one fetus or more, first trimester, fetus 2.
Finally, when coding multiple gestations, O30._, the codes have been expanded to include the number of gestations, amniotic sacs, and placentae, in addition to the 7th character designation for the affected fetus. For example: O30.212, Quadruplet pregnancy with two or more monochorionic fetuses, second trimester.
2017 CHANGES IN OBSTETRICS
Chapter 15 includes expansions for many categories. The ectopic pregnancy codes (O00) have been expanded to include without intrauterine pregnancy and with intrauterine pregnancy. A category of codes for molar pregnancy (O09.A) has been added. Codes 010 - O16 Edema, proteinuria and hypertensive disorders in pregnancy, childbirth and the puerperium have also been expanded to code for complicating childbirth and complicating the peurperium.
A new code has been added for the use of oral hypoglycemic drugs: O24.415 Gestational diabetes mellitus in pregnancy, controlled by oral hypoglycemic drugs. Category O34.21 Maternal care for scar from previous cesarean delivery has been expanded to identify the different types of scars. Codes have been added to O44 Placenta previa to specify the type of previa. Finally, the codes for third degree perineal laceration have been expanded to include the degree of laceration:
O70.2 Third degree perineal laceration during delivery
In Chapter 21 Factors influencing health status and contact with health services (Z00-Z99), there is a change to the weeks of pregnancy codes, Z3A._. The description has been changed to add the words if known: Z3A Weeks of gestation - Note: Codes from category Z3A are for use, only on the maternal record, to indicate the weeks of gestation of the pregnancy, if known. In addition, there are new Z codes for "gestational carrier":
2017 CHANGES IN GYNECOLOGY
In Chapter 14, Diseases of the Genitourinary System, the category N39.4 Other specified urinary incontinence has been expanded to include three different types of urinary incontinence. Two types of inflammatory disorder of the breast have been added, N61.0 Mastitis without abscess and N61.1 Abscess of the breast and nipple. Category N83 Noninflammatory disorders of ovary, fallopian tube and broad ligament now includes laterality, for example N83.11 Corpus luteum cyst of right ovary.
Codes have been added to N90.6 Hypertrophy of vulva and N94.1 Dyspareunia to expand the types of conditions captured by the code set. A new code was created for N93.1 Pre-pubertal vaginal bleeding. Finally, category N99 Intraoperative and postprocedural complications and disorders of genitourinary system, not elsewhere classified has been greatly expanded.
Chapter 21 has a few additions affecting the gynecological practice. For Encounter for routine gynecological examination ICD 10 now provides the options of with abnormal findings and without abnormal findings. Several contraceptive choices have been added to Z30.4 Encounter for surveillance of contraceptives:
DOWNLOAD THE ICD 10 UPDATES FOR OB/GYN
These documents are in Word format for easy editing by your staff:
If you have any questions about OB/Gyn coding, or anything else pertaining to your revenue cycle management, please do not hesitate to get in touch by clicking the Contact Us button below.