submitting quality codes on individual Part B claims. The quality codes are comprised of CPT Category II codes – “F” codes – and HCPCS Category II codes – “G” codes. For detailed information on measures by specialty, review the PQRS Measure Specifications Manual, which indicates which quality data codes should be used for each measure. The Qualified Clinical Data Registries (QCDRs) have received a lot of attention. These registries are different from the regular "qualified registry" option because they use non-PQRS measures and require reporting on all patients, not just Medicare. Specialtyboard and society-clinical-data registries would qualify as vehicles Physician quality programs are expanding as the shift to collaborative care, outcome-based payment and new benefit designs transforms how healthcare is delivered and paid for. for participation (e.g., Society of Thoracic Surgeons National Database or ACR). In some cases, this will allow the provider to meet requirements for board maintenance of certification and PQRS simultaneously. Additionally, CMS stated in the 2015 Medicare Physician Fee Schedule Final Rule that it intends to eventually eliminate claimsbased reporting. Value-Based Modifier The Affordable Care Act mandates that CMS apply a value-based payment modifier (VM) to payments by 2015 for groups with 100 or more eligible providers (by tax ID number). The requirement will apply to groups with 10-99 providers in 2016 (based on 2014 PQRS reporting), to solo practitioners and groups of 2-9 in 2017, and to nonphysician practitioners in 2018. The VM will assess a cost composite score, which equals the total overall costs plus total costs for beneficiaries with specific conditions. The program will assess quality indicators for clinical care, patient experience, patient safety, care coordination, and efficiency. There are many details related to the program that must be finalized and communicated to the healthcare industry. It appears that the overall goal of the VM program is to calculate a cost composite score plus a quality composite score to equal the value modifier amount. 18 HBMA BILLING • MARCH.APRIL.2015 Groups that are subject to the VM in 2015 that did not successfully participate in 2013 via GPRO will receive a 1 percent penalty (in addition to the PQRS penalty). This is not related to the CMS EHR Incentive Program (Meaningful Use). If the qualifying group (100+ EPs) participated via claims reporting and not the GPRO option in 2013, they will not avoid the penalty in 2015. PQRS is the basis for VM, so the penalty will be based on PQRS measure performance rates of group practices and eventually individual physicians. For 2015, those groups that participated in PQRS can choose to have their “value modifier” at a level of 0 percent or to potentially receive an upward or downward adjustment through quality tiering. Quality tiering is a voluntary option under VM that allows group practices to earn a bonus or be subject to a penalty for their group’s performance on quality, outcomes, and cost measurements. The program is budget neutral, so if some physicians/groups get more, some must get less. As with PQRS, the stakes for VM are rising. Groups of 10 or more that do not meet requirements for satisfactory PQRS reporting for 2015 services will be subject to a 4 percent VM payment reduction in 2017. Also, under the quality-tiering mechanism, groups of 10 or more will be subject to a 4 percent payment EXAMPLES OF VALUE-BASED MODIFIERS Quality/Cost High Quality Average Quality Low Quality Low Cost +2.0x* +1.0x* 0.0% Avg. Cost +1.0x* 0.0% -1.0% High Cost 0.0% -1.0% -2.0% “X” indicates the factor for the VM upward adjustment; % determined by aggregated downward adjustments, maintaining the program in budget neutral fashion * indicates an additional +1.0x upward adjustment for treatment of high-risk beneficiaries
Billing_MarApr15
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