Category: Value-Based Care

MIPS Reporting Year 2020 Guidance Update

MIPS Reporting Year 2020 Guidance Update

After weeks of waiting, CMS has finally updated its MIPS guidance around the Reporting Year 2020 (RY2020). While CMS may make additional changes, this is the first major change for RY2020 we have seen thus far. For 2020, physicians and groups reporting for MIPS may submit an Extreme & Uncontrollable Circumstances Application to have some or all the MIPS categories reweighted to 0%. You must justify how COVID-19 has harmed your ability to achieve the category (or categories) you are asking to have reweighted.

Unlike the last-minute automatic reweight of RY2019, this will require effort on your organization’s part. You must provide examples showing:

  • How the pandemic prevented you from collecting necessary MIPS data for a category (or categories) (such as seeing patients only via telemedicine and no reliable method of collecting Quality Category data)
  • How the pandemic will prevent you from scoring a category (such as missing 3 months’ worth of Quality Category data)
  • How the pandemic impacted your normal business process that would affect your cost measures or other administrative claims measures (such as unable to send claims due to lack of enough billing staff)

SHP’s Recommendation

We recommend that if you intended to submit for RY2020 and you feel your data is complete enough to score well, continue to move forward with that plan. A reweight request of a category may result in a lower score than desired. A total reweight of MIPS will result in a score of 0, with penalty avoidance, but may harm your score on Physician Compare:

That said, if you do feel like a reweight will help your organization and you feel that you can justify the request to CMS, follow the instructions here:

As always, SHP is here to help you with your Quality Payment Program participation questions, and we will bring you timely information regarding any changes to the MIPS program for 2020 and beyond.

COVID-19 & MIPS Reporting Year 2020

Despite the on-going health crisis, the Quality Payment Program is still in full swing for Reporting Year 2020. MIPS practices, ACOs, and APMs are all expected to report their 2020 performance in Q1 2021. So far, CMS has only made some minor alterations to the QPP/MIPS program, largely focused on some “housekeeping-type” changes that will give QCDRs a little more breathing room. That said, CMS has indicated there will be changes coming to the MIPS program, but they have not given a clear timeline or any idea on what will change.

What Has Changed?

  • The biggest change has already come and gone, the data submission deadline for RY 2019 was moved to April 30. Those who did not submit data by that deadline were given a neutral adjustment instead of a penalty as the pandemic trigged an “Extreme and Uncontrollable Circumstances (E&UC) policy” exemption. Practices and providers that did submit will receive their adjustment accordingly.
  • New Improvement Activities (high-weight) for RY2020 were created that promotes participation in COVID-19 treatment clinical trials and reporting on COVID-19 data to a registry or data repository.
  • Extended the deadline for the QCDR measure & collection policies from Jan 1, 2021 to Jan 1, 2022. (This will require QCDRs to follow new rules for gathering more measures and sharing “unique” measures with others)
  • Extended the Call for Quality Measures & the submission of DVER to June 30

What Will Change?

At this point in time, it would be pure speculation as to what will change. The largest lobby groups have advocated for a 90-day reporting window for all four categories, another automatic trigger of the E&UC policy, a nation-wide “pause” on QPP, and other substantive changes. We won’t know until sometime this summer or even this fall if there will be any changes to this reporting year.

Therefore, it is our recommendation to proceed with your RY2020 plans and do not plan on making any modifications to your QPP behavior. Expect that while CMS will make changes, if you continue on the “there’s no change” path you will likely exceed their modified rules whenever they are released.

When CMS does release their changes, we will be here to post an update and provide education to help you understand and best navigate the rules.

What to Consider With Fee-For-Value Health Plans

Health plans, Centers for Medicare and Medicaid Services (CMS), and national news are touting the ongoing move from straight fee-for-service healthcare into fee-for-value healthcare. Upon initial glance, fee-for-value models absolutely provide new revenue streams for healthcare providers. However, when considering a fee-for-value partnership with a health plan; it is critical for providers to fully consider their dependency on the health plan for accurate, detailed reporting and reconciliation. Whether it is recognizing all submitted diagnosis codes for accurate risk adjustment or financial allocation of the patient’s care; providers have very little ammunition to fight any performance indicators rendered by a health plan.

Even providers currently in fee-for-value arrangements and receiving regular incentives or distributions from health plans cannot accurately assess whether they are maximizing their opportunities without relying on the health plan. Particularly for Medicare Advantage, providers are the key partners that allow the health plan to maximize revenue through risk adjustment and STARS performance and providers should ensure that they are accurately reaping the rewards that the health plan is receiving.

This lack of transparency becomes even more critical as providers consider the move to downside risk.  Accepting financial responsibility for a health plan’s determinations can become detrimental without any method of independently verifying those results.  These are important considerations for all providers to make when partnering with a health plan in a fee-for-value model.

Click here to learn more about our contracting services and how we can help you evaluate your options.

FHIR Finally Breathing Interoperability

Business connection concept.

With 82% of hospitals and 64% of Merit-Based Incentive Payment System (MIPS) Eligible Clinicians using EHR technology supported by Fast Healthcare Interoperability Resources (FHIR®), it might be time for patients, providers, and health systems to finally expect complete and centralized personal health records. FHIR is a pivotal turn for Health Level Seven (HL7®) to essentially turn your EHR into an application platform allowing immediate access to secure data sources, like your iphone, android, or smart TV centralizes banking information, mobile health information, and an endless supply of capabilities competing for screen time. FHIR provides a secure transformation of health information across disparate data sources, this ultimately can lead to reduced administrative quality reporting burdens, more timely transfers of personal health records (PHRs) across EHRs, even reliable biometric data monitoring within PHRs, and much more.

This swift technological advancement breaks down data exchange barriers, largely in pursuit of population health capabilities encouraged by HL7s Argonaut Project which health information technology juggernauts such as Epic, Cerner, AthenaHealth, and provider organizations like Intermountain Health and Mayo Clinic. To a layperson, these organizations are using FHIR to essentially share meaningful clinical data on secure internet-based platforms (Think of an https:// address) called resources, that allow other entities to build off of this flexible set of data, including imaging results, lab tests, longitudinal care plans, etc.

This industry sweeping capability raises the temperature for data blocking, recently referred to as ‘patient profiteering’ by CMS administrator Seema Verma who points out the financial incentives for health systems, vendors, or payors that purposefully contort patient data to maintain market share. The Office of the National Coordinator for Health Information Technology (ONC) will soon propose further teeth in the 21st Century Cures Law by defining data blocking instances to penalize with fines and decertification.  This proposal is expected in December, which will then lead to a period of public comment. Congress has specifically focused on defining and regulating application programming interface (API) capabilities that halt data-sharing by intentionally forming proprietary data agreements to gain competitive market advancement.

So, what’s the point? Interoperability may not be a day-to-day must-have for most providers and administrators in 2019, however it could finally connect disparate sources of health information in a clinically and practically relevant fashion in the very near future.  Real-world clinical practice scenarios will drastically transform if FHIR continues to gain traction as the world’s brightest technology innovators compete for providing the most clinically relevant information sharing, within your existent EHR platforms.

Capitol Watch: Legislative Day 35

Legislative Day 35
It’s been a busy week at the State Capitol with many twist and turns as we see the legislative session
and term make its way to the end. We’ve seen many bills placed on other bills and an attempt to get
them passed this year. We will be on high alert in the remaining days. Please watch for alerts as we
close out the session.

Thriving in the Quality Payment Program

If there is one universal given in healthcare today, it’s the complexity and fear of the unknown of the Quality Payment Program (QPP), or MACRA, whichever title you prefer. From provider feedback, we have crafted an actionable approach to allow healthcare providers better understand and thrive within the value-based world of the QPP. As these sweeping reimbursement adjustments continue to shift Fee-For-Service healthcare towards a convoluted payment mechanism involving quality, cost, and electronic health record utilization, we have dedicated staff keeping up with these changes to keep providers up to speed.

Most recently, we were offered the privilege to present at the 2017 Conference for The Georgia Medical Group Managers Association (GMGMA) to discuss the strategic implication with our peers. In the true spirit of collaboration and desire to increase an understanding of this evolving landscape, we’ve provided a link to our recent presentation below. We hope it provides you with a better grasp of the QPP model, the program’s details, and action steps to succeed. Please contact us with questions regarding the impact of MIPS, MACRA, QPP, and whichever other “Macra-nym” that comes to mind.


Thriving in the Quality Payment Program


How to Bill: Transitional Care Management

Transitional Care Management (TCM) bolsters the involvement of primary care physicians in the coordination of post-discharge care to reduce readmission. Patients with moderately complex diagnoses are eligible to receive TCM services during a 30-day window after their discharge from an inpatient acute care hospital, inpatient psychiatric hospital, long-term care hospital, skilled nursing facility, inpatient rehabilitation facility, or hospital outpatient observation.
Physicians must make interactive contact with the beneficiary and/or caregiver within two business days following the beneficiary’s discharge. This contact may occur via telephone, e-mail, or face-to-face. Successful direct contact must be documented, therefore voicemails or e-mails without responses will not qualify.

One face-to-face visit must occur within the timeframes as described by CPT 99495: Moderately Complex -14 Days; 99496 Highly Complex-7 days.
Additionally, non-face-to-face services are required unless deemed not medically necessary. These services may be furnished by licensed clinical staff under the general supervision of a physician. This team-based care approach offers flexibility for clinical staff to locate beneficial resources and communicate regularly with their patients while working “at the top of their licenses.” Licensed clinical staff are expected to provide education, self-management advice, and encourage treatment regimen adherence.

How do we bill TCM?

The three requirements for TCM Billing

1. Interactive Contact made within 2 business days of discharge
2. Face-to-face service within 7- or 14- calendar days of discharge, depending on complexity
3. Non-face-to-face services rendered by licensed clinical staff

The following documentation within the patient’s record is essential:

➢ Discharge Date
➢ Date interactive contact was made
➢ Date the face-to-face visit occurred
➢ The complexity of medical decision making

Who may furnish which non-face-to-face TCM services?

Physicians (any specialty) and Non-physician practitioners (NPPs) including Certified nurse-midwives (CNMs), Clinical nurse specialists (CNSs), Nurse Practitioners (NPs), Physician Assistants (PAs) may furnish the following non-face-to-face services:

o Obtain and review discharge summary or continuity of care documents
o Review need for follow-up on pending diagnostic tests and treatments
o Interact with other healthcare professionals who will assume or reassume care of the beneficiary’s system-specific issues
o Provide education to the beneficiary, family, guardian, and/or caregiver
o Establish or re-establish referrals and arrange for needed community resources
o Assist in scheduling required follow-up with community providers and services

• Clinical staff under general supervision of a physician or NPP, under applicable state law may furnish the following non-face-to-face services:

o Communicate with agencies and community services applicable to the beneficiary
o Provide education to the beneficiary, family, guardian, and/or caretaker to support self-management, independent living, and activities of daily living
o Assess and support treatment medication adherence and treatment regimen compliance
o Identify available community resources
o Assist the beneficiary in accessing needed care and services

Common Considerations

➢ TCM services can be reported even if the patient is re-admitted
➢ The face-to-face visit may not occur on the day of discharge
➢ Report reasonable and necessary evaluation and management services (other than the required face-to-face visit) separately
➢ TCM services cannot be paid if any of the TCM period falls within a global period for a procedure code billed by the same practitioner
➢ The place of service of the face-to-face visit is to be reported on the claim
➢ Only one health care professional may report the TCM services
➢ When billing 99495 & 99496, You may not also report the following codes:

o Care plan oversight services: Healthcare Common Procedure Coding System (HCPCS) G0181 and G0182
o End-stage Renal Disease services: 90951-90970
o Medical Team Conferences 99366-99368
o Telephone Services: 98966-98968, 99441-99443
o Chronic Care Management (CCM) and TCM service periods cannot overlap

More Info: Transition Care Management Services – Medicare Learning Network

PQRS to MIPS Quality Metric Mapping

The 2,171-page final rule contains several differences that crosswalk existing PQRS measures to new finalized metrics. The simplest way to ensure your PQRS-to-MIPS transition goes smoothly is to search each quality metric and data submission method here.

Several important tables for your reference from the final rule:

  • Table A (Page 1,902) outlines each of the available MIPS Quality measures.
  • Table D (Page 2,019) explains each of the brand-new MIPS Quality measures.
  • Table F (Page 2,114) contains each of the PQRS measures that are no longer available in the MIPS Quality Program.
  • Table G (Page 2,126) identifies PQRS that were subjected to “substantial changes,” for the MIPS Quality Program.


Keep in mind, to submit enough data for a “moderate positive adjustment,” in the 2017 Performance Year, you need to submit 6 measures, including one outcome measure, or one high-priority measure for a minimum of a continuous 90-day period. Specialists can also report specialty-specific sets, some of which contain fewer than 6 measures but many include 10+ measures.