MACRA Made Easy – The Final Rule Released

On Friday October 14th CMS released the final rule of MACRA.  Since many providers and staff that we encounter still have not even heard of MACRA despite being bombarded with emails and newsletters with information, we will start at the beginning.

MACRA is The Medicare Access and CHIP Re-Authorization Act which was signed into law in 2015 and is slated to be implemented in 2019.  Even though it will not be implemented until 2019 it will be based on performance data from 2017.  Many providers seem to be ignoring the information on MACRA.  Maybe because they see the year 2019 and figure they still have time, or maybe because it is just too darn confusing to figure out.  In either case, ignoring MACRA can be a costly mistake.

Basically MACRA takes the Meaningful Use (MU) Electronic Health Record Incentive Program, Physician Quality Reporting System (PQRS), and the Value-Based Modifier (VBM) program and combines them all into one Merit-Based Incentive Payment System (MIPS) program.

What does that mean to providers or Eligible Professionals (EPs)?  Well it means that EPs will be assigned a MIPS composite performance score.  This score will be calculated on a scale from 0 to 100 and will significantly influence their Medicare reimbursements.  In 2019 a provider’s payments may be anywhere from -4% to +4% depending on their MIPS composite performance score.

The MIPS composite performance score will be divided into the following components:

60% Quality (PQRS)  –  If providers are not reporting PQRS then they are could have a score of 40 or below right off the bat.

25% Advancing Care Information – This was previously known as Meaningful Use or EMR.  If providers are not demonstrating Meaningful Use then they could lose 25 points of their MIPS composite performance score.

15% Improvement Activates  –  EPs will be able to choose from a list of activities that best fit their practice.  At least one activity must be selected.  The activities are categorized as “medium” or “high” weight.  Full credit for this portion of MIPS is 60 points.  A high weight category earns 20 points and a medium earns 10.  One way an EP can earn 60 points would be to participate in three high weight activities from the list.

MACRA replaced the old Sustainable Growth Rate (SGR) method of determining fee schedule amounts for providers.  Providers will now have fee schedules that will be determined by their MIPS composite performance score.  So it is possible that providers in the same physical location can have completely different reimbursement rates.  This is not simply a 1.5% or 2% penalty.  This will determine the fee schedule and may result in providers receiving up to -9% by the year 2022.

The problem is that the score will be based on data from two years prior so the provider will have to deal with the lower fee schedule for up to two years in order to rectify the situation.  Providers need to understand that the claims that they submit and the actions (or lack of action) they take beginning January 1, 2017 will affect their Medicare reimbursement in 2019.

If an individual EP works for more than one group, the performance score is a weighted average.  If the individual EP changes groups, the performance score is based on the data from the previous period.  So for example, if an EP works for Middleville Health Clinic for the entire year of 2017, but then switches to Johnstown Medical in 2018, their performance score for payments in 2019 will be based on their reported data from Middleville Health Clinic in 2017.

If an EP is newly enrolled, or they are below the low-volume threshold of $10,000 for the reporting year, then they will have no MIPS score and will be considered exempt for that year.
If an EP has Medicare billing charges less than or equal to $10,000 AND provides care for 100 or fewer Medicare patients in one year they are not subject to MIPS.

Prolonged Service Add-on codes now apply to outpatient mental health

The add-on codes for prolonged services, 99354 and 99355 are now applicable to face-to-face outpatient mental health as well as for E/M codes.  Previously these codes were only reimbursable if used with E/M codes.
+99354 – Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service, first hour
+99355  –  Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service, each additional 30 minutes
Previously CPT code 90837 was the longest code to report individual psychotherapy.  The 90837 indicates 60 minutes.  If a doctor or therapist saw a patient longer than one hour there was no way to report the additional time.  With this new rule, add-on codes can be used to report the additional time.
For example, if a psychologist spends 90 minutes with a patient face to face for individual psychotherapy they would report the 90837 and the 99354.  If they spent two hours and thirty minutes, it would be reported using the 90837, 99354, and one unit of 99355.
It is important that the patients chart is noted with the time spent with the patient.  Even though these add-on codes can be applied to outpatient mental health it doesn’t mean that all insurances or all plans will cover the add-on codes.  Also, prior authorization rules would still apply as well.
They have also created two new add-on prolonged service codes.  +99415 and +99416 are to report prolonged face to face services performed by a physician, NP or PA.  These prolonged service codes start at services > 45 minutes.
Note:  The + in front of a CPT code indicates that it is an add-on code and that a primary CPT code must be used.

New Mandates in Medical Billing

Recently we have seen more mandates regarding the medical billing field.  Our local Blue Cross recently offered direct deposit by signing up for ERAs and switched from Payspan to another service.  Most of our providers opted for the direct deposit but when the ERAs started coming through in a totally different format than providers were used to we had one provider in particular who didn’t like the new format and wanted to go back to the old paper checks and EOB.  We called Blue Cross to see if this was possible but were told that yes they could change back but soon it would be mandated and they would have to reapply then.

Also AETNA has announced that as of January 1, 2017 ALL claims must be submitted electronically.  They did send out a nice letter explaining what to do regarding appeals, attachments, secondary claims, corrected claims and COB information.

Patient Payment Collections

Even before the enactment of the ACA patient responsibilities were increasing.  However with the ACA plans we are seeing them climb ever higher.  It is not uncommon to see $40 or $50 co-pays and $2500 deductibles.  With patient responsibilities rising it is becoming crucial for providers to improve their patient payment collections.

In the past when most of a visit was paid by insurance this was not as important.  Now it is not uncommon for the entire allowed amount to be the responsibility of the patient so providers cannot afford to not collect the patient portions.

With the technology available, providers now have more options.

  1. Most important is sending patient statements on a regular monthly basis
  2. Co-pays should be collected at the time of service and should not require sending a statement except in unusual situations
  3. Patient statements can now be sent by email cutting down on costs
  4. Statements can be sent with a place for the patient to enter credit card information to pay the balance.
  5. A patient portal can be set up on a website to accept electronic payments over the internet.
  6. If time allows in the office patients should be called to remind them of past due balances and an attempt should be made to set up payment arrangements
  7. Providers can consider using “soft collections” through a collection agency where the collection agency makes several calls and sends letters over a brief period of time attempting to set up payment arrangements.

People are more accustomed to making payments by EFT or paying bills online with a credit card.  It is important that providers give patients convenient ways to make their payment.


Initial Encounters and Diagnoses Codes

Many practice management systems allow the storage of a patient’s diagnoses codes in their record.  Then when a claim is created the diagnoses codes are automatically populated.  This can be a huge short cut in some cases.  For example, a patient being seen for outpatient psychotherapy usually has the same diagnosis code visit after visit.  So every time the a claim is generated the diagnosis code is automatically entered saving the biller the need to add it.  However this can cause denials is certain situations.

Some diagnosis codes must be changed depending on whether it is an initial encounter or a subsequent visit.  For example; if a patient is seen for a right sprained ankle and the initial visit ICD10 diagnosis code of  S93.01XA is used, subsequent visits would be billed with ICD10 code S93.01XD.  The S93.01XD code is specifically for subsequent visits while the S93.01XA is specifically for an initial encounter.

So if a PMS system that allows storage of diagnoses codes is used make sure to check the claims over for accuracy.

Avoid denials for unspecified codes

ICD10 Grace Period Ending October 1, 2016

Hard to believe that it has been almost a year since ICD10 was implemented.  Have to admit that from our point of view the implementation went fairly smoothly with just a few bumps.  But we were warned that Medicare and other commercial carriers were going to allow a grace period of one year for non-specific ICD10 codes.  After one year claims with unspecified ICD10 codes will be denied.

That one year grace period ends October 1st.  We have actually already seen a few denials for unspecified codes but we are expecting that number to rise after October 1st.  We have been reminding our providers to be as specific as possible when coding.  Providers that are using the unspecified codes as primary diagnoses will probably see many denials one the grace period ends.

There are things that can still be done to prevent this.  If a provider is still using a superbill make sure the codes on the superbill allow them to indicate the specifics.  For example, if a patient has a sprained ankle make sure the provider can indicate if it is the right or left ankle.  Also, is this the first visit for the sprain, or is this a subsequent visit?  Is it a subluxation or a dislocation?  All of this information is required in order to use a non specific ICD10 code.

Most EHR systems help with this issue by giving the options when the provider is documenting the visit.  If the provider is using an EHR program, make sure it allows for them to pick the specific code when documenting.

Educate your providers.  Let them know that if they don’t use specific codes or provide the information so that specific codes can be assigned they will disrupt the cash flow.  Many times the provider is still unaware that it is important to indicate right or left, or other specific information needed to select the correct ICD10.

The biggest thing is don’t wait.  Take a look at the situation now and try to prevent the denials.  Check the billing currently going out to see if unspecified codes are being used.  Identify the areas that need to be improved and implement systems to fix them now before the denials start to come.  This will prevent the disruption to the provider’s cash flow.

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