June 14, 2017
NARHC Website has New Look + Increased SSL Security
The NARHC Website has a new look & feel plus additional SSL security! We hope you like it!
May 23, 2017
NARHC Addresses Senate Press Conference
WASHINGTON, D.C.–The National Association of Rural Health Clinics (NARHC) was invited to speak at a Senate press conference on rural health hosted by Senator Martin Heinrich (D-NM). NARHC President John Gill stressed the important role Medicaid plays in allowing RHCs to provide care in rural communities. John emphasized that the average RHC sees a much greater percentage of Medicaid patients than the average fee-for-service clinic and therefore RHCs are particularly concerned about any potential cuts or changes to the Medicaid program that could reduce Medicaid payments to RHCs. Senator Martin Heinrich (D-NM) opened the press conference and was followed by Senator Bob Casey (D-PA), Senator Tom Udall (D-NM), and Senator Al Franken (D-MN) who all made comments on health care reform and its impact on rural health.
From left to right Senator Tom Udall, Senator Martin Heinrich, NARHC President John Gill, Senator Al Franken and Dr. Robert Rosenberg speak at a Senate Rural Health Press Conference.
April 26, 2017
Raising the RHC Cap?
A question was posed about the prospects for raising the RHC cap and when this might occur. Raising the RHC cap requires an Act of Congress as the cap is set by law. The current cap is an extension of the RHC cap established in 1988 ($46.00 per visit) adjusted for medical inflation over the intervening 29 years. Obviously it is very out-of-date.
We do not anticipate that Congress will begin to look at Medicare reforms until the Fall at the earliest. We anticipate that much of the Congressional Calendar over the next few months will be devoted to efforts aimed at repealing/replacing the Affordable Care Act and tax reform.
We believe there is strong bi-partisan support in Congress for raising the RHC cap; however, that optimism is tempered by the realization that to do so would result in a significant increase in Medicare expenditures. Under current rules, any change in the Medicare law that results in higher expenditures must typically be offset by savings elsewhere in the Medicare program. So the challenge in raising the RHC cap is not convincing Members of Congress of the need to raise the Cap, it is identifying cuts in the Medicare program that would offset the higher expenditures associated with raising the cap.
Let’s presume that Congress agreed to raise the RHC Medicare cap to $110 per visit as proposed by the Senate Rural Caucus (a bi-partisan coalition of Senators representing largely rural states). Estimates are that this would increase total Medicare spending on RHCs by approximately $150 Million per year or more than $1.5 Billion over ten years. This means that concurrent with raising the cap, Congress would have to cut $150 Million per year or more than $1.5 Billion over 10 years somewhere else in the Medicare program. Finding spending cuts of that magnitude – while not impossible – would be a challenge.
Now, as large as that number – $150 Million – seems to most of us, it is also important to point out that Medicare spending on RHCs constitute less than 1% of Medicare spending. So $150 Million is – in budget terms – a rounding error in Medicare spending.
So I cannot say when the RHC cap might be raised by Congress. We’ve been pushing this for several years.
Finally, I would mention that the NARHC staff is also looking at options and ideas for improving the financial viability of RHCs subject to the cap. Some of these alternatives would not require a change in the RHC statute and could provide financial relief comparable to what would be accomplished by raising the RHC cap. We will have more on this as these ideas evolve. Hope this lengthy explanation is helpful in understanding the opportunity and challenge we face in raising the RHC cap.
April 18, 2017
Policy & Procedure Manual Template
Below are some options. I would strongly recommend that you use these as templates. Also, please note that the P/P manual in the “How To” publication is getting old and likely needs to be updated but it will still give you a sense of how you may want to proceed. It is extremely important that the P/P manual be a reflection of how YOUR RHC intends to practice and see/treat patients.
Keep in mind that the manual must also reflect the unique laws and regulations governing medical practices in your state. So a manual developed from one state may not cover of the things that would be necessary in your state due to practice nuances or state regulatory requirements (not necessarily RHC but general state medical/nursing laws) in your state.
Several RHC consultants have also developed RHC Policy and Procedures manuals that they sell or otherwise make available. You may want to consider contacting an RHC consultant if you don’t find that either of the documents linked below meet your needs. I would discourage use of a cookie cutter approach. That having been said, here are some options for you to consider:
RHC How To Manual produced by NARHC a few years ago. A sample P/P is included in this document.
And this from the Oregon Health Sciences University. Although specific to provider-based clinics, much of what is in this would be relevant to independent RHCs as well. Hope this helps.
March 27, 2017
Are Visits to an SNF by an RHC Provider an RHC visit?
Recently, an NARHC News listserve participant posted a question/concern regarding a comment she heard during a webinar conducted by the Medicare MAC – Noridian. The commenter stated that the representative from Noridian stated that visits to a SNF by an RHC provider were not RHC visits and should be billed on the 1500 claim form and not billed on the UB-04. If correct, this would constitute a significant change in CMS policy (as well as the Medicare statute).
NARHC contacted the Noridian representative to whom the above comments were attributed and sought clarification. Here is what we asked and the responses to our inquiry:
NARHC News Commenter stated:
“In that Webinar she stated that Providers that go to a SNF to render services are outside of the rural health clinic and should be billed as a non-RHC encounter and on a 1500 form. I asked again during the Q&A and she reiterated this as fact according to the IOM.”
In response, the Noridian representative said that she was specifically referencing a situation in which the RHC provider was NOT being compensated by the RHC during the time the visit occurred. Specifically:
If the RHC physician is not compensated for services provided in the SNF the physician may bill on the 1500 form.
We also sought additional clarification by writing: First, did you say that SNF visits were not billable as RHC visits on the UB-04 claim form and if so, why?
No RHC visits can take place in a SNF. I was listing non-RHC services which the IOM states that a NON-RHC service is a service where the RHC does not compensate a physician service (RHC Part One slide 64).
The Noridian answer is correct but it is important that you pick up the specific context. “… the RHC physician is not compensated for services provided in the SNF” by the RHC.
SNF visits by RHC providers are RHC visits and billable as an RHC encounter on the UB-04 Claim form. We hope this helps to clear up any misunderstanding and we appreciate that Noridian staff responded to our inquiry in an effort to ensure that there was no lingering confusion.
Updates from Cahaba on RHC Claims
Nov. 29, 2016
ALL RHC Medicare claims – whether “single line” or “multi-line” MUST have the CG modifier on the “pay” line. If a single line, the CG modifier goes on the single line with the HCPCS code for that RHC visit.
If multi-line, then the CG modifier goes on the line (typically the line that is the principle reason for the visit) on which you have rolled up all of the charges for the encounter. This lets CMS know that this is the line on which they should base the beneficiary co-insurance.
If you had claims rejected because the claim did not have the CG modifier, then you will need to re-file the claim. Here is a link to the instructions for re-filing a Cahaba claim: http://www.cahabagba.com/documents/2012/02/part-a-fiss_correct.pdf
CG Modifier & Cahaba
Nov. 23, 2016
As many of us know, beginning October 1, most RHC Medicare claims (with a few exceptions) were required to have modifier CG on the claim. While we (the NARHC) communicate billing updates through this listserv as soon as we learn about them, this is ultimately a responsibility of each MAC to communicate these updates to their jurisdiction.
NARHC staff has discovered that Cahaba did a very poor job of communicating the Oct. 1 CG changes to their providers. A significant number of RHCs in Cahaba’s jurisdiction were completely unaware of the CG modifier changes. Making matters worse, Cahaba’s customer service department was also not aware of these billing changes, even though their IT department had updated their system per the Oct. 1 guidelines.
As a result, RHCs that were oblivious to the CG modifier changes started calling Cahaba and inquiring why their claims were being denied. Unable to accurately diagnose the problem (that there was no CG modifier on the claims), Cahaba’s customer service department began telling people that it was a “system” problem on Cahaba’s end and that they were working on a fix.
NARHC staff has confirmed with CMS central staff that this is not a problem with the FISS or some other Cahaba system, but rather a severe lack of communication within Cahaba, and to Cahaba providers, around the CG modifier changes.
The good news is that CMS and Cahaba realize the true nature of the problem now, and we have been told that Cahaba is actively working on getting all their departments on the same page here. We have made it clear that Cahaba needs to detail specific instructions on how RHCs should refile the claims that were rejected for not following the CG rules. We anticipate that Cahaba will issue a correction soon that explains their oversight and properly educates their RHC providers on the CG changes.
NARHC Director of Government Affairs
Election First Take Analysis
November 10, 2016
The following is our quick analysis of the election for your reading pleasure. NARHC will also be creating a more RHC-centric analysis and sending that out sometime next week via List Serve.
Two days ago, Republican candidate Donald Trump was elected as the 45th President of the United States. Trump defeated his Democratic opponent, Hillary Clinton, despite an overwhelming sense by almost everyone going into Election Day that Clinton would win.
Trump’s 276 electoral votes, which is only six more than are required to win the election, does not speak for the decisiveness of his victory. Those who paid close attention to polling data and projections on reputable websites, such as 538 and Real Clear Politics, expected a very close race with Clinton edging out a win. Not only did Trump outperform projections in most of the up for grab “swing” states such as Pennsylvania, North Carolina and Florida, he was also able to win several states that historically vote Democrat that he was not expected to have a chance of winning. The most notable of these states include Wisconsin and Michigan.
Most pundits and pollsters dismissed the possibility of a “Trump effect” in which Trump outperformed polls due to the people being surveyed not wanting to go on record that they were supporting Trump. The Trump effect played a significant role in the primary elections. Trump had also narrowed a lead that Clinton held over the past two weeks. In fact, Trump was polling within the margin of error in many of the states he won.
This was, by any measure, a transformational election. It was an “insiders” vs. “outsiders” election more than a “liberals” v. “conservative” election at the Presidential level. It was also an economic election. Places like Pennsylvania, Ohio, Wisconsin and Michigan voted red. While the national economic numbers are improving, general confidence in the economy has yet to make a full recovery after the great recession. Many Americans felt that they have been passed over. This was middle class America’s “I will not be ignored” moment.
Looking down the ticket, the House of Representatives will remain in Republican control. This was always expected. The Senate will also remain in Republican control despite a much less certain outlook going into Election Day. However, Republicans will not have a “super majority” of 60 seats needed to override a Senate filibuster. The results of the House and Senate elections will be covered in greater detail later in this document.
But now the work begins.
It is worth noting that this will be the first time the GOP has controlled the House, Senate and White House since 1928 so this is something none of us have ever experienced. The Republicans will also now be able to nominate a ninth Supreme Court Justice, which could swing the political balance of the court towards conservative ideology.
The GOP victories down ticket (House and Senate) suggest that there are opportunities to get things done in the legislative arena that may not have been possible under divided government. We still have the filibuster in the Senate but it is possible that we will see, particularly in the first 100 days, legislation enacted that makes some significant changes in policy. The GOP had the odds against them relative to the number of seats they were defending relative to the Democrats. But those tables are turned in 2018 when more than 20 Democratic Senate seats will be up and only a handful of GOP seats. Trump is a negotiator, not an ideologue, so he will likely be open to deals that wouldn’t be possible under a more ideologically driven politician. Democrats up for re-election in 2018 may be inclined to “work with” the new President, particularly if they are in a “red” state.
With regards to health policy, this may result in some down-the-road changes to MACRA but the core will remain. MACRA enjoyed strong bi-partisan support and will likely continue to enjoy bi-partisan support. However, changes could be made that might have been unrealistic just a few weeks ago.
Additionally, key provisions of the Affordable Care Act (ACA) are in jeopardy (individual mandate, employer mandate). It may also accelerate Health Plan departure from the ACA Exchanges because they want more in the way of protections from risk and those are not likely to occur under a GOP Congress. Lack of a filibuster-proof Senate means a full repeal of the ACA is unlikely but dramatic changes will likely occur.
Trump and the GOP Congress can, despite the filibuster, use Budget Reconciliation – the same legislative process President Obama used to pass some of the key provisions of the ACA – to repeal and or replace key provisions of the ACA with only a simple majority. Some provisions of the ACA, such as protections for patients with preexisting conditions and allowing consumers to remain on their parent’s insurance plan until they are 26, remain popular and could exist in some form under a Republican alternative.
Reconciliation could also be the likely process for enacting a tax refor
RHC Guide to the MACRA Final Rule
October 28, 2016
We understand that there are a lot of questions and interest around MACRA (Medicare Access and CHIP Reauthorization Act) especially around the specifics of how it does and does not affect RHCs. We have put together the following Q&A to address many of the relevant aspects of the final rule for RHCs.
It is important that we make a distinction at the outset between RHC claims – those submitted for RHC services using a UB-04 claim form and traditional Medicare Part B claims submitted by Physicians, PAs and NPs using an individual or group NPI using a 1500 claim form.
Q: Will my RHC All-Inclusive Rate be affected by the new Medicare Incentive Payment system (MIPS)?
A: No. The final rule states that because RHC services furnished by eligible clinicians (Physician, PAs and NPs) are not reimbursed under the Medicare PFS (Physician Fee Schedule), RHC services are not covered by the MIPS program. Reimbursement for RHC UB-04 claims will be unaffected by this new program. The RHC Cap will continue to adjust each year to reflect medical inflation and productivity improvements.
However, non-RHC claims submitted by RHC Physicians, PAs and NPs to Medicare Part B (i.e. items billed on a 1500-form) may be affected (see below).
Q: Will non-RHC services (billed on a 1500) using the individual/group NPI be affected by MACRA?
A: Potentially. We believe MOST RHC physicians, PAs and NPs will fall under a low-volume exemption threshold (see below), which will exempt these clinicians and their 1500 claims from MIPS reporting and payment adjustments.
Q: What is the low-volume threshold?
A: CMS has determined that Physicians, PAs and NPs who do not submit sufficient Medicare Physician Fee Schedule (1500) claims will be exempt from the MIPS program. These are classified as “low-volume” providers. A low-volume provider is defined as a Physician, PA or NP who, during the low-volume threshold period,
- Has billed Medicare Part B allowed charges of $30,000 or less during the billing cycle; OR
- Provided care to 100 or fewer Medicare Part B-enrolled beneficiaries during the billing cycle.
RHC claims are NOT counted when determining whether or not a clinician meets the threshold.
- What billing cycle will CMS use to do the claim or patient count?
CMS will review Physician, PA and NP Medicare Physician Fee Schedule billing for the 24 months preceding the reporting year broken into two, separate 12 month calculations or “billing years”. These will not be calendar years but rather so-called “billing year”. For 2017 (2019 payment adjustment year), the “billing year” reviewed by Medicare will be claims submitted between September 1, 2015 through August 31, 2016. CMS will conduct a second “billing year” calculation based on claims submitted between September 1, 2016 through August 31, 2017 to determine additional eligible clinicians and groups.
If the individual Physician, PA or NP claim submissions are $30,000 or less during EITHER of these billing years, the clinician will be considered exempt from MIPS for the associated Payment Adjustment Year. Each year after 2017, CMS will conduct a similar review with the older year dropping from the calculation and the most recent September – August “billing year” being added to the calculation. Again, as long as the Physician, PA or NP meet the low volume criteria during either of the two years, the clinician would be deemed MIPS exempt.
CMS will also use this same 24 month review method to do the patient count.
Q: How will Medicare know if an individual clinician provides care to fewer than 100 Part B-enrolled Medicare beneficiaries?
A: CMS will use social security numbers reported on 1500 claims to determine this part of the exclusion. This is a count of patients, not claims. For example, if an eligible clinician provides multiple services to one RHC beneficiary over the course of the “billing year”, this only counts as one Medicare enrolled beneficiary for purposes of the low-volume threshold.
Q: Will Clinicians have to apply for the low-volume exemption?
A: No. CMS says it set up the low-volume threshold determination period in such a way that will allow CMS to notify Physicians, PAs and NPs who qualify for the exemption during the month of December preceding the quality reporting year. CMS has not specified how notification will occur. We expect that CMS will issue guidance on this within the next few weeks.
Q: How is CMS identifying individuals versus groups for the purposes of the low-volume exclusion?
A: For individuals, the low volume threshold exclusion is determined by the Tax ID Number (TIN)/National Provider Identifier (NPI) combination. For groups, low volume exclusions are determined by simply the TIN. Individual eligible clinicians that are part of a group that chooses to report as a group, will be required to participate in MIPS if the entire group qualifies.
For example, if five RHC eligible clinicians are a part of the same group (TIN) and each eligible clinician bills $10,000 of allowable Medicare Part B charges, then that group has the option to report as a group and be subject to MIPS as a group (meaning they all get one group quality score) or to report as individual eligible clinicians and take the low-volume exemption.
In this example, if they report as a group with total Medicare allowable charges of $50,000, then their Part B claims are going to be required to report MIPS quality data to CMS and have their Part B (1500) claims subject to MIPS adjustments (positive or negative). However, if the clinicians report individually, $10,000 per, then all five would be exempt from quality reporting and exempt from MIPS adjustments (positive or negative) on their Medicare Part B claims.
Q: If an eligible clinician qualifies for the low-volume exclusion, can they chose to opt-in to MIPS and receive an adjustment?
A: No. Once it has been determined that for the reporting year a clinician or group is deemed “low-volume”, the clinician or group is ineligible to participate in MIPS for that reporting year.
Q: Can Rural Health Clinics voluntarily report MIPS data?
A: Yes RHCs may voluntarily report MIPS data and receive a MIPS CPS score. However, any MIPS data reported on RHC services would not be used for the purposes of the MIPS payment adjustment on non-RHC claims.
At some point Congress may propose to extend the MIPS program to RHCs and it would be helpful to know how RHCs would fair under the MIPS data reporting requirements.
Oct. 26, 2016
CMS has produced an FAQ document that addresses many of the questions/scenarios relative to the use of the CG modifier that have been raised on this listserve.
I strongly encourage you to review this document.
As will see when you review the document, there is an FAQ that addresses one of the scenarios you posed by Lori Donals:
- If a medical service and a preventive service are furnished on the same day, should modifier CG be reported with both services?
- No. Modifier CG should be reported only with the medical service HCPCS code that represents the primary reason for the medically necessary face-to-face visit when medical and preventive services are furnished on the same day.
To your specific examples.
Scenario One: It should be the line (CPT code) that was the primary medical reason for the visit. So if in the scenario you are using, the primary medical reason the patient came into the RHC was for skin lesion removal (CPT 17000) and you also performed the introductory to Medicare physical (G0402). The CG modifier goes on the line where you report the 17000.
In this specific situation, you would get two AIR payments. One for the medically necessary visit (17000) and one for the IPPE (G0402). The coinsurance would be applied to the lesion removal (medically necessary visit) and there would be no coinsurance for the IPPE (it’s waived for this service).
Scenario two: Again, the CG modifier goes on the line that is the primary reason the patient came into the RHC for a visit. Because both are preventive visits, there is no “medical” or “mental health” visit. So here, you get to choose. Did the patient come in for the IPPE (G0402) or the Well Woman exam (G0101) and you combined them into the same visit? Either way, you pick one that is “primary” and you put the CG modifier on that line.
Typically, only one line of the claim requires the CG modifier. The principle exception to this is if you provide BOTH a Medicare covered medical visit and a Medicare covered mental health visit to the same patient during the same visit, then both lines would have the CG modifier. This is typically going to be the only time you’d have the CG modifier on the claim more than one.
Hope this helps.
Oct. 1, 2016
Hopefully everyone is aware of the HCPCS reporting changes set to kick in next week. The best place to review those changes is here: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1611.pdf
We also wanted to clarify a few things regarding these changes.
- The CG modifier should be used even when the only service listed on the UB-04 claim is a preventive service.
- HCPCS codes G0436 and G0437 will be discontinued effective for dates of service after 10/1/2016. The proper codes for tobacco cessation counseling are 99406 and 99407.
- For purposes of RHC billing, modifiers 25 and 59 are interchangeable. We have confirmed this with CMS.
National Association of Rural Health Clinics
2018 Essential Community Provider List & Petition
Sept. 1, 2016
Under the Affordable Care Act (ACA), Qualified Health Plans (QHPs), are required to include essential community providers (ECPs) that serve predominantly low-income, medically-underserved individuals in their networks
Rural Health Clinics are eligible for designation as ECPs
As part of the Plan Approval process, the Secretary Health and Human Services (HHS) has established criteria mandating inclusion of a sufficient number and geographic distribution of ECPs in an issuer’s network to ensure reasonable and timely access to a broad range of such providers for low-income, medically-underserved individuals in their service areas.
To demonstrate satisfaction of the ECP requirement, Qualified Health Plans must submit a list of ECP’s in the Plan’s network with whom the Plan has contracted to provide health care services to low-income, m edically-underserved individuals in their service areas. Failure to meet the ECP criteria would be grounds for rejection of the Plan’s application.
The Department of Health and Human Services (HHS) has compiled a draft non-exhaustive list of available ECPs for plan year 2018. These providers submitted an ECP petition by July 11, 2016, and were approved by CMS through the ECP petition review process. Nearly 1,000 federally certified RHCs have already been approved by HHS as ECPs.
You can see if you are on the approved ECP list by going to the searchable database and searching for your clinic by name. If you are NOT on the list, you can petition to be an ECP by going to the ECP petition webpage. If you are on the list and there is an error you would like to correct, you can do so on the ECP Petition webpage.
The Draft HHS ECP list for the 2018 benefit year is also embedded within ECP petition and can be viewed by clicking the button “Check to see if you are on the list” under question 6 of the ECP petition webpage
CMS is accepting petitions from qualified providers until 11:59 p.m. ET on October 15, 2016, for data corrections and additions to be considered for the 2018 ECP List. RHCs who need technical assistance with the petition or may have general questions may receive assistance by emailing their question(s) to the following mailbox:
Providers should write “Comments on ECP Petition.” in the subject line of the email.
HCPCS Reporting Requirements Starting Oct. 1st
Oct. 1, 2016
CMS recently released a new MLN Matters article detailing the new HCPCS reporting requirements starting on October 1, 2016. The article can be accessed HERE.
As expected, we will no longer have to deal with a qualifying visit list. Instead, we will simply use the modifier “CG” to indicate to CMS which service line should be subject to coinsurance.
Director of Government Affairs
RHC Chronic Care Management Claims
June 28, 2016
If you have been experiencing problems with your RHC CCM claims being paid incorrectly, the corrective action to “fix” the CMS claims processing system is schedule to be installed on July 11th. CMS has released the following statement. Note that the MAC should automatically reprocess any CCM claims that were paid the incorrect amount and no refiling of the claims on the part of the RHC is required.
Chronic Care Management Payment Correction for RHCs and FQHCs:
Effective January 1, Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) began receiving payment for Chronic Care Management (CCM) services. Payment should be calculated based on the Medicare Physician Fee Schedule national average non-facility payment rate. CMS is aware that RHCs and FQHCs have been receiving a locality adjusted payment rate for CCM services. Your Medicare Administrative Contractor will adjust any claim processed incorrectly. No provider action is required.
MACRA, MIPS, APMs, RHCs and You
May 26, 2016
Many of you may be aware that CMS recently published a proposed rule implementing a significant piece of legislation known as “MACRA”. This rule, once finalized, will significantly change the way physicians using the Medicare Physician Fee Schedule are reimbursed for Medicare services. Naturally, many people have asked: Does this affect RHCs? At least for the near-term, the answer is: mostly no.
However, this does not mean the RHC community should ignore this proposed rule. Some of the initiatives in it may very well make their way into the RHC payment methodology at some point in the future.
Merit-Based Incentive Payment System (MIPS)
Under MIPS The Merit-Based Incentive Payment System (MIPS) physicians, PAs and NPs billing Medicare using the Physician Fee Schedule will required to report various measures which will be used to determine end-of-year payment adjustments. Although RHCs are exempt from the reporting requirements, CMS has provided RHC eligible clinicians the opportunity to “voluntarily report on applicable measures and activities for MIPS.” RHC clinicians opting to voluntarily report will have no bearing on RHC payments.
MIPS combines three quality programs (PQRS, value modifier, and EHR Meaningful Use) into one. Eligible clinicians receive an overall score called the Composite Performance Score (CPS) which then dictates what kind of Medicare Physician Fee Schedule (PFS) payment adjustment that eligible clinician will get for the corresponding payment year. Roughly half of all clinicians will receive some upward adjustment and half will receive a downward adjustment.
Similar to PQRS, MIPS does not apply to RHC services, however non-RHC services such as labs or anything billed on a 1500 form could be subject to MIPS reporting and MIPS adjustments. Unlike PQRS, there is a low-volume exemption for individual providers who “have Medicare billing charges less than or equal to $10,000 worth of allowable claims AND provides care to fewer than 100 Part B-enrolled Medicare beneficiaries.” It is our estimation that full-time RHC practitioners would likely not bill $10,000 worth of non-RHC PFS services, but could feasibly see (as an individual) 100 Medicare patients. As such, we will be asking CMS to consider changing the low-volume exception in the final rule to: bill less than $10,000 worth of claims OR fewer than 100 Medicare patients.
For those who may be interested in learning more about how MIPS works, we would refer you to our summary of the program.
Alternative Payment Models (APMs)
The ultimate goal of these payment reforms is to “encourage” providers to participate in Alternative Payment Models (APMs). These models go beyond the MIPS quality scores by incorporating quality with shared financial risk to the providers. The hope is that these APMs will transition the healthcare system from paying for volume to paying for value. For over a year, we were unsure of exactly what qualified as an APM for the purposes of MACRA, but the proposed rule gives us the first details of how these models will be structured.
Clinicians can avoid MIPS negative payment adjustments if they are instead “qualified” by their participation in so-called “advanced APM models”. Clinicians qualify if a certain percent of their revenue comes from or a certain percent of their patients participate in an “advanced APM model”.
It is important to note that the term APM has been used to describe various different “models” but many of those “APMs” do not qualify as “advanced APM models” for the purposes of MACRA.
Providers that qualify because they reach the threshold of revenue-from patients-in an APM, are considered “Qualifying Participants” and will receive a lump sum incentive payment equivalent to 5% of their total Medicare reimbursement. Because RHCs are not reimbursed under the Physician Fee Schedule (PFS), RHC services would not be considered part of the amount upon which the APM incentive payment is based.
We should note that RHCs can participate in ACOs – a type of advanced APM model – but have numerous caveats for their participation. Those RHCs that are considering joining an ACO, or are already in one, should carefully review this section of the proposed rule.
While the MIPS and APM models get their own yearly adjustments. The RHC cap will continue to be adjusted based off of medical inflation.
RHC Billing for Chronic Care Management
May 26, 2016
NARHC has been notified by CMS that there is an error in their system and RHCs are not being paid correctly for Chronic Care Management services. CMS is working on the problem. NARHC has been assured that once it is fixed, CMS will issue a notice that all RHC claims for CCM services will be automatically reprocessed and adjusted, and no action will be required by the RHCs.
We do not have a projected timeline for when the problem will be resolved but we are hopeful that it will not take long. Once we are notified that the problem has been fixed, we will post that on this listserve.
MIPS / MACRA CMS Proposed Rule
May 23, 2016
The following memo summarizes and analyzes provisions of Merit-Based Incentive Payment System (MIPS) in the so called “MACRA” CMS proposed rule.
We would note that for the sake of brevity, we could not dig into the technical details on everything. Instead we have tried to pull out the most significant aspects for purposes of our discussion. However, we have included links throughout this summary for those who wish to dive into the details.
Who will participate in MIPS?
Those clinicians affected by this rule are called “MIPS eligible clinicians” and for years 1 and 2 of MIPS will include: physicians, PAs, NPs, Clinical Nurse Specialists and Certified Registered Nurse Anesthetists. The Secretary may broaden this group after year 3 to include other health professionals (i.e. PTs, OTs, etc.). CMS anticipates that most clinicians will be subject to MIPS (as opposed to APMs or being exempt) especially for year 1.
CMS estimates that between 687,000 and 746,000 eligible professionals will be subject to MIPS in 2019. CMS also estimates that somewhere between 30,658 and 90,000 eligible clinicians will be exempt from MIPS because of their participation in APMs or due to a “low volume” exemption.
How can clinicians participate?
Clinicians can participate as either an individual or as a group as defined by a taxpayer identification number. Depending on how you are participating, you will have slightly different reporting mechanisms/requirements.
How does MIPS score work? – Overview
Each clinician or group would receive a score from 0-100 in each of the following 4 weighted categories (percentage is year 1 weight):
-Resource Use (10%)
-Clinical Performance Improvement Activities (15%)
-Advancing Care Information Performance (25%)
Those scores would then translate into something called MIPS Composite Performance Score or CPS. Payment adjustments will be determined off of the CPS. Over time, the percentage for Quality will phase down to 30% of the total and the percentage for Resource Use (Cost) will rise to 30%. The Clinical Performance Improvement Activities (CPIA) and the Advancing Care Information Performance (ACIP) will remain unchanged.
Quality performance category overview (50% of CPS)
MIPS eligible clinicians would report at least six measures of their choosing. The measures must including one so-called “cross cutting” measure and at least one “outcome” measure. If there is no applicable “outcome” measure, then clinicians must use one “high priority” measure. MIPS eligible clinicians can select any applicable measure of the over 300 measures in total.
Additionally, all MIPS eligible clinicians will be scored on 3 “population-based” measures. These are: 1-Acute Conditions Composite, 2-Chronic Conditions Composite, and 3-the All-cause Hospital Readmission Measure.
So what exactly are these measures the clinicians choose from?
There is no easy way to look at these because CMS has released the measures in a “table” format that is not easily portrayed in a word document. The full list of measures can be found in the Appendix of the NPRM document.
Table A – list of all measures to choose from – begins on page 773
Table B – population based measures that all MIPS eligible clinicians will be measured on-begins on pg 823
Table C – list of cross cutting measures – also begins on page 823
Table D – proposed new measures – begins on page 825
Table E – list of measures broken out by specialty – begins on page 836
How do these measures affect the MIPS quality score?
Each measure a clinician reports will be given a score of 1-10. For example an orthopedic surgeon who has selected his/her 6 measures (including 1 cross-cutting and 1 high priority), would be scored on a scale of 1-10 for each of the 6 measures. Additionally, the clinician would be measured on their 3 population based measures via a 1-10 scale.
So in total we have 9 measure with a max possible score of 90. If the physician scores a 70/90 then they would receive a 78% on the quality portion of the CPS. There are, of course, caveats to all of this. For instance, MIPS eligible clinicians participating via a group have to report more measures (up to 17), certain specialties that don’t have 6 applicable measures can report less, etc. There are also bonus points awarded for various activities and measures.
On each measure, CMS will create what they call a measure benchmark. Essentially, a measure benchmark will be based on previous reported scores for that measure. Although not exactly an average, it will be a score that is representative of where a significant percentage of clinicians scored previously on that measure. The clinicians will then be given points based on how they do against their peers. If you rank in the 55% percentile according to their benchmark, for example, then you will get roughly 5.5/10. The following Table demonstrates how the scoring for a particular quality measure would look:
Furthermore, CMS is aware that many of their measures are easier to achieve than others. CMS wants to discourage clinicians from picking the “low hanging fruit” and constantly strive for improvement. Therefore, CMS penalize clinicians for picking the so-called “easy” measures. CMS does this by creating something called a “topped out measure” which is essentially a measure where a large percentage of clinicians reported a 100 performance rate. In those cases they have developed a formula to make it impossible to get the full 10 points for that measure. Essentially they want to encourage clinicians to report the measures that may not be topped out. Table 18 gives you an idea of how these topped out measures would work:
We should note that CMS would like to measure and reward improvement but is soliciting comments on how best to implement this concept. They have laid out 3 options beginning on page 324 if you would like to further examine.
Resource Use performance category overview (10% of CPS)
All measures used under the resource use performance category are derived from Medicare administrative claims data so there is no need to use another data submission mechanism. Furthermore, all measures attributed to the MIPS eligible clinician will be scored. If an eligible clinician has only one resource use measure with a required case minimum to be scored, CMS would score that measure accordingly. The resource use performance category borrows most of the measures from the existing CMS value modifier (VM) program including:
-Total per capita cost measure
-The MSPB measure
-Episode based measures
These measures will have risk adjustment as previously adopted under the VM. These will basically adjust the expected cost of each beneficiary based on the Hierarchical Condition Category model. Here is a refresher on how that works.
How does the Resource Use scoring work?
The Resource Use scoring works very similar to the existing CMS resource use scoring concept (QRUR). Essentially, eligible clinicians get a score from 1-10 on each applicable measure based on a benchmark that puts all eligible clinicians on a bell curve. One of the key differences is that, CMS will use the performance year to determine the benchmark as opposed to the “baseline” year.
The higher the cost per each measure, the lower the score. Those “expensive” clinicians will receive a low category score.
Clinical Performance Improvement Activities Performance Category Overview (15% of CPS)
Think of the CPIA performance category like a checklist. If you did the improvement activity, you get the credit for that activity. In general, CMS expects the MIPS eligible clinician to perform the improvement activity for at least 90 days. This is strictly reporting. No value or quality component to the activity.
Unlike quality and resource use, CPIA is a new program, and thus no baseline will be used for the first year. Instead each CPIA is assigned a “medium” weight worth 10 points, or a “high” weight worth 20 points. MIPS eligible clinicians will need to report 60 points worth of CPIA activities in order to receive a 100 on their CPIA scoring portion. For instance, an eligible clinician could report 6 medium weight activities, or 4 medium and 1 high weight activities in order to achieve 60 points total.
Unlike the measures in the quality and resource use programs, the CPIAs are activities where you either meet the criteria to say you did that activity or you didn’t. If you did the activity you will receive the full ten or twenty points. Table H on page 946 in the proposed rule lists all the CPIAs available for the first year.
Advancing Care Information Performance Category Overview (25% of CPS)
The successor to Medicare EHR Incentive Program, the ACIP score is comprised of both a “base score” and a “performance score”.
The “base score” involves reporting the numerator and denominator of measures adopted by the EHR Incentive Programs Stage 3. The base score accounts for 50% of the ACIP. MIPS eligible clinicians must report the numerator and denominator or yes/no statements as appropriate for each measure within a subset of objectives. Similar to the CPIAs, if clinicians report the required items properly, they will get full credit.
The “performance score” consists of eight measures each worth 10 possible points. For instance, one of the measures asks clinicians to report the total number of prescriptions they write and the total number of prescription generated via a certified EHR. If a clinician gets submits 100% of their prescriptions via a certified EHR, their performance rate for this measure would be 100. Unlike the base score, the performance score is implemented off of a decile scale. So clinicians will be rated based off their percentile of performance, similar to the quality measures scoring system.
Each of the eight measures in the performance score is worth 10 points towards the full ACIP score (so up to 80%). The base score is then added with the performance score to determine the overall ACIP score. It is possible to get over 100 on the ACIP score, but those excellent performers would be capped at 100 for purposes of calculating their CPS.
How the Overall CPS score is calculated – Overview
So we have briefly described how the 4 inputs to the CPS score will work and be scored. The weights for each of the scores work logically as you might expect. So for demonstration purposes lets calculate a hypothetical CPS score.
CATEGORY SCORE 2019 WEIGHT WEIGHTED SCORE
Quality Performance Category 75 50 37.5
Resource Use Performance Category 60 10 6
Clinical Performance Improvement
Activities Performance Category 100 15 15
Advanced Care Information
Performance Category 80 25 20
Composite Performance Score CPS N/A N/A 78.5
Incorporation of Risk Factors in the CPS score
The proposed rule, for lack of a better term, largely “punts” on including risk factors in the overall CPS scoring methodology. While there is some risk adjustment (via HCC scores) in the resource use input category, there is as of right now, no other place where risk factors are seriously considered. The proposed rule does acknowledge that the law requires CMS to consider risk factors in their scoring methodology. They note that the ASPE is currently conducting studies and making recommendations “on the issue of risk adjustment for socioeconomic status on quality measures and resource use.” Then they state that they will “closely examine the recommendations issued by ASPE and incorporate them as feasible and appropriate through future rulemaking.”
MIPS Payment Adjustments
Once everyone has their CPS score, CMS must then determine who gets the 4% upward adjustment, who gets the 4% downward adjustment, and who falls somewhere in the middle. To do this they are going to establish a “Performance Threshold” based on either the mean or median as selected by the Secretary of all the CPS scores.
CMS would then establish a linear scale by which the actual payments adjustment would be made. Of course, there are numerous caveats, but the general idea is that if your CPS score is above the performance threshold, you will receive an upwards adjustment. If your CPS score is below the performance threshold, you will receive some downward adjustment. CMS provides the following figure to help explain:
May 18, 2016
The Rural Health Clinic payment system is EXEMPT from the recently proposed MIPS initiative. MIPS is a payment adjustment (up or down) that will be applied to fee-for-service payments by Medicare beginning in 2019. Clinicians participating in MIPS will begin reporting data in 2017 that will determine their 2019 payment adjustment. The scoring for MIPS (0 – 100 point scale) will be a composite of individual/group reporting on PQRS, EHR Meaningful Use, Cost/Resource use and other quality/cost reporting requirements.
If an RHC wishes to drop their RHC status and bill fee-for-service and be subjected to MIPS, you have that option. For 2019, the maximum MIPS upward adjustment will be 4% and the maximum MIPS downward adjustment will be 4%. The MIPS program is revenue neutral meaning that CMS must “pay for” the upward adjustments with money recouped from physicians, PAs and NPs whose payments are reduced under MIPS. For 2019, the amount of the adjustments will be $833 Million. So physicians/PAs/NPs getting upward adjustments will get a total of $833 Million and physicians/PAs/NPs getting downward adjustments will have $833 million taken back by Medicare.
Keep in mind that MIPS is in lieu of automatic adjustments.
In 2019, it is estimated that the RHC cap will be automatically adjusted upwards approximately 1.2% with NO risk of downside adjustment. This will have followed two years (2017 and 2018) of automatic upward adjustments in the cap. So for the possibility of getting an additional 2.8% increase in 2019 (meaning you are one of the top performing practices in the United States) you would also be subject to a potential 4% reduction if you do not score at least in the top 1/2 of providers in the country on your MIPS score.
CMS estimates that over 80% of small practices (one or two practitioners) billing fee-for-service will experience a payment reduction under MIPS.
For RHCs not subject to the cap, annual increases are based upon clinic-specific cost increases with no downside adjustment risk. These uncapped RHCs represent the majority of RHCs.
NARHC has not taken an official position on asking CMS to expand the MIPS initiative to include RHCs. Given that RHCs have no exposure to downside adjustments and either mandatory upside annual adjustments (i.e. cap increases) or the ability to get higher payments due to higher clinic specific costs, I’m not sure that in the near-term, it would be in the best interest of MOST RHCs to participate in MIPS.
Having said that, I do believe that RHCs should have the opportunity to demonstrate that they provide quality care and be rewarded for meeting appropriate quality benchmarks. NARHC has supported this concept for some time and the Federal Office of Rural Health Policy has been working to develop RHC specific quality benchmarks.
In the MIPS proposed rule, CMS proposes to allow RHCs to begin voluntarily reporting MIPS quality data. While this is an attractive opportunity on its face, we also need to be concerned that CMS could draw inaccurate or inappropriate conclusions if voluntary reporting is limited.
NARHC is continuing to review the MIPS/APM proposed rule and will likely make comments on this major reform prior to the mid-June deadline.
RHC CPT Reporting
May 10, 2016
CMS has released a new MLN Matters Article that clarifies how the CG modifier will work, and how exactly to bill all those claims you are holding until Oct. 1.
The key section:
In April 2016, CMS instructed RHCs to hold claims only for a billable visit shown in red on the RHC QVL until October 1, 2016. Upon billing these claims and/or for claim adjustments beginning on October 1, 2016, RHCs shall add modifier CG (policy criteria applied) to the line with all the charges subject to coinsurance and deductible. The subsequent paragraph explains modifier CG further.
Beginning on October 1, 2016, the MACs will accept modifier CG on RHC claims and claim adjustments. RHCs shall report modifier CG on one revenue code 052x and/or 0900 service line per day, which includes all charges subject to coinsurance and deductible for the visit. For RHCs, the coinsurance is 20 percent of the charges. Therefore, coinsurance and deductible will be based on the charges reported on the revenue code 052x and/or 0900 service line with modifier CG. RHCs will continue to be paid an all-inclusive rate (AIR) per visit.
For the full article, click HERE.
Director of Government Affairs