Preparing for 2013 and Beyond: Provisions That Will Impact Your Practice Beginning in 2013
In the year ahead, there are several policy changes that could significantly impact your reimbursement for future years and how you practice medicine and sustain practice operations.
As your practice prepares for these new initiatives, ASGE stands ready to be a reliable and timely resource in helping you navigate these changes in 2013 and beyond.
Is your practice prepared?
Below are six policy changes that could affect your practice. For additional information or questions, please contact Lakitia Mayo, ASGE Assistant Director for Health Policy and Quality at lmayo@asge.org.
- Physician Quality Reporting System
- Physician Value-Based Modifier for Groups of 100 or More
- Electronic Prescribing Payment Adjustment
- ASC Quality Reporting Program
- OIG Seeks Practice Compliance Vulnerabilities
- CMS Seeks Valuation Review for Over 100 Endoscopy Procedures
Physician Quality Reporting System
The Physician Quality Reporting System (PQRS) is a Centers for Medicare and Medicaid Services (CMS) reporting program that uses a combination of incentive payments and payment adjustments to promote quality data reporting.
Avoiding a reduction in CY 2015 Medicare Part B reimbursement will require successful participation in PQRS in 2013.
For 2013 and 2014, the Affordable Care Act (ACA) authorizes a 0.5 percent incentive payment for physicians, group practices and other eligible professionals who successfully participate in PQRS. The law also calls for payment reductions of 1.5 percent and 2.0 percent in 2015 and 2016, respectively, for eligible professionals who do not satisfactorily report data on quality measures for covered professional services during the reporting year. The reporting year for the 2015 payment year is 2013.
Group practices with two or more eligible professionals can participate in PQRS through the Group Practice Reporting Option (GPRO). Group practices wanting to participate in the GPRO must self-nominate and elect their reporting mechanism by October 15, 2013.
To avoid the payment adjustment in 2015, CMS has finalized for eligible professionals and group practices three options for meeting the criteria for satisfactory reporting:
- Meet the criteria for earning the 2013 PQRS incentive; Report one measure or, for eligible professionals only, a measures group; or
- Elect to be analyzed under an administrative claims-based reporting mechanism.
GIQuIC, the ASGE/ACG registry, now offers registered physicians an opportunity to submit PQRS measures using the registry mechanism at no additional cost, thanks to its partnership with the Outcome PQRS registry.
For 2013, CMS has offered several opportunities in reporting to help physicians avoid receiving the negative payment adjustment in 2015. Registration is not required to begin reporting. Additional information on how to get started can be found at www.cms.gov/pqrs.
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Physician Value-Based Payment (VBP) Modifier for Groups of 100 or More
The Value-based Payment (VBP) Modifier and PQRS are aligned. CMS is required by law to phase in application of a VBP modifier to physician Medicare payments beginning January 1, 2015. By 2017, the VBP modifier must be applied to all physicians.
As the first phase, in 2015 CMS will apply the VBP modifier to groups of physicians with 100 or more eligible professionals. CMS will determine a group’s 2015 value modifier as follows:
- Category 1: Groups that self-nominate for the PQRS GPRO by October 15, 2013 and: a) report at least one measure; or b) elect the PQRS administrative claims option for 2013. VBP modifier = 0.0 percent, meaning no payment adjustment will be applied in 2015.
- Category 2: Groups that do not fall into Category 1. VBP modifier = -1.0 percent, meaning physicians will receive 99.0 percent of the paid amounts for physician fee schedule items and services.
Groups in Category 1 can choose to have their VBP modifier calculated using a quality-tiering approach. This option would allow these physician groups to earn an upward adjustment for high performance, although the groups could be at risk for a downward payment adjustment (which could be no lower than –1.0 percent) for poor performance. Because the value modifier is being implemented in a budget neutral manner, CMS cannot specify the exact amount of the upward payment adjustment.
The 2015 and 2016 VBP modifier does not apply to groups that are participating in the Medicare Shared Savings Program, the testing of the Pioneer accountable care organization model, or other similar CMS Innovation Center or CMS initiatives.
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Electronic Prescribing Payment Adjustment
For 2013, eligible professionals and group practices that are successful electronic prescribers (ePrescribe) will receive a 0.5 percent incentive payment.
The minimum group practice size for participation in the ePrescribe Group Practice Reporting Option is two. For a group practice of 2-24 eligible professionals, to be a successful electronic prescriber the group must report the electronic prescribing measure at least 75 times between January 1, 2013 and December 31, 2013. To avoid the 2014 payment adjustment of –2.0 percent, the group practice must report at least 75 times between January 1, 2013 and June 30, 2013.
The rule also adds two new hardship exemptions for avoiding the 2013 and 2014 negative payment adjustment.
If physicians believe they meet one of the Medicare electronic prescribing (ePrescribing) hardship exemptions but did not file by the June 30, 2012 deadline, CMS has extended the deadline to apply for hardship. CMS has reopened the Communications Support webpage to give physicians more time to file for a hardship to avoid the ePrescribing penalty. Available hardship exemptions include physicians who are:
- unable to ePrescribe due to state, federal or local law/regulation;
- with fewer than 100 prescriptions between January 1, 2012 and June 30, 2012;
- in rural areas without sufficient high-speed Internet access; or
- in areas without enough pharmacies available for ePrescribing.
Many of the ePrescribing penalties received in 2012 by physicians who filed for a hardship exemption were due to filing errors. Therefore, it is important to know that hardships should be filed using the physician’s individual Type I NPI. That is, the rendering Provider NPI used for box 24(J) of CMS 1500 form, or the NPI used in the Rendering Provider Name loop or the Billing Provider Name loop, if the billing provider and rendering provider are the same on the 837 (electronic claim) and the Tax ID number (TIN) they use to bill. For physicians who bill using their Employer Identifier number (EIN), they should use their EIN for filing a hardship and those who bill using their Social Security Number (SSN) should use their SSN for filing hardship.
Please visit www.CMS.gov/ERxIncentive for additional information and resources. If you have questions regarding the ePrescribing Program or need assistance submitting a hardship exemption request, please contact the QualityNet Help Desk via qnetsupport@sdps.org or at 1-866-288-8912 (TTY 1-877-715-6222).
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ASC Quality Reporting Program
A quality data reporting program for Ambulatory Surgical Centers (ASC) was finalized by CMS this year. The ASC Quality Reporting Program began October 1, 2012.
ASCs that do not meet the ASC Quality Reporting Program requirements for the 2012 performance year will receive a 2 percent reduction in their annual payment update in 2014.
To meet the ASC Quality Reporting Program requirements and avoid the payment reduction in 2014, ASCs must submit quality-data codes (QDCs) for five measures on the paper or electronic version of the Form CMS-1500 for October 1, 2012 to December 31, 2012 services where Medicare is the primary payer. ASCs must submit at least 50 percent of their Medicare paid claims with the appropriate QDCs by April 30, 2013 to receive the full annual payment update.
For the 2015 payment determination, ASCs must submit QDCs on their claims beginning with January 1, 2013 services where Medicare is the primary or secondary payer and submit structural measure data using a web-based tool.
For the 2015 payment determination, in addition to the same claims-based measures reported in 2012, CMS has added two structural measures that will be reported via a Web-based tool. The reporting period for the structural measures will begin on July 1, 2013 and extend through August 15, 2013 for services furnished between January 1, 2012 and December 31, 2012.
The first step is to begin reporting with QDCs, which are specified CPT® Category II codes, or Level II G-codes that describe the presence or absence of an event.
Second, ASCs must register with QualityNet to establish a Security Administrator in order to report required structural measures data during the July 1 to August 15, 2013 time period and to access data submission reports. ASCs may register beginning in February 2013.
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OIG Seeks Practice Compliance Vulnerabilities
The Office of Inspector General (OIG) of the U.S. Department of Health and Human Services has released its 2013 Work Plan. The OIG has developed a voluntary compliance program document that may help in your efforts to ensure your compliance with Medicare and Medicaid laws and regulations. The AMA also developed resources that provide the basic structure that physicians and others may follow for establishing a compliance plan that can be incorporated into the physician practice.
New and continuing areas of focus for physicians as outlined in the 2013 OIG Work Plan include:
- Medicare and Medicaid Incentive Payments for Electronic Health Records Potentially Inappropriate E & M Payments in 2010 relating to EHR documentation
- Noncompliance With Assignment Rules and Excessive Billing of Beneficiaries
- Error Rate for Incident-to-Services Performed by Non-physicians
- Place-of-Service Coding Errors
- Use of Modifiers During the Global Surgery Period
- Non-Hospital-Owned Physician Practices Using Provider-Based Status
- Payments to Providers Subject to Debt Collection
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CMS Seeks Valuation Review for Over 100 Endoscopy Procedures
The GI community is facing a comprehensive review of the valuation of physician work and practice expense for more than 100 endoscopy procedures in response to a request from CMS. ASGE along with the AGA is asking physicians to complete surveys of these endoscopic procedures.
The GI community needs significant participation from gastroenterologists to complete these surveys of physician work in order to provide realistic recommendations to the AMA’s Relative Value Update Committee (RUC). Not receiving a minimum number of responses for each survey puts GI at risk for having CMS make the final decision regarding valuation of GI endoscopy procedures without consideration of our input.
If you are selected for a survey, please participate. More active GI physicians that practice in community and academic-based and private and hospital-based settings need to complete the RUC surveys. Whether you perform routine esophagogastroduodenoscopy (EGD) and colonoscopy or more complex procedures such as endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound or stenting, your help is needed. To volunteer for these surveys, please email surveys@asge.org with your name and contact information. If you are a practice manager, please urge your clinician colleagues to volunteer for this vital process.
Educational materials are available with information that makes participating in the surveys easier. Educational materials specific to the current survey as well as the endoscopy survey timeline are posted on the RUC process page on the ASGE website.
Physician participation in the survey process is essential to obtaining accurate valuation for endoscopic procedures. Please contact ASGE staff, Sam Reynolds, at sreynolds@asge.org with any questions regarding this process.
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Additional ASGE Resources to Help Your Practice Prepare for 2013
- GI Outlook (GO) Conference 2013: This premier practice management conference will be held in downtown Chicago August 9-10, 2013. GO 2013 promises to deliver insightful and relevant programming to physicians, practice managers and administrators.
- Endoscopic Unit Recognition Program: This program promotes quality in endoscopy by encouraging endoscopy offices, centers and units to adhere to ASGE guidelines on privileging, quality assurance, endoscope reprocessing, and infection control. Today, more than 300 units have been awarded this recognition.
- Improving Quality and Safety in your Endoscopy Unit: This course is designed to thoroughly review principles of quality and safety as recommended in published guidelines. The next course is scheduled for February 18, 2013 in San Francisco, CA.
- GIQuIC: A quality improvement benchmarking tool for gastroenterology practices. GIQuIC is designed to help physicians improve clinical outcomes through higher-quality procedural services and to set the stage for improved performance reimbursements from Medicare and private payers.
- Coding Questions and Practice Management Inquires: As a membership benefit, ASGE has created a team of physicians, coding experts, and practice managers to answer questions specific to gastroenterological coding and practice management.
- Advocacy and Regulatory Compliance Webpage: Visit this webpage to receive the latest information and guidance on regulatory changes that could impact your practice from agencies like CMS, FDA, and CDC.