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Report and Avoid Medicare Penalties

The Centers for Medicare and Medicaid Services (CMS) says thousands of psychiatrists are providing services reimbursed under Medicare Part B. The Merit-based Incentive Payment System (MIPS) is part of Medicare's new Quality Payment Program (QPP). MIPS payment adjustments begin in 2019, and depend on your performance score from two years earlier. So now is the time to take action to avoid penalties in 2019.

Step 1: Must I Do 2018 MIPS Reporting to Avoid 2020 Penalties?

NO, I do not have to report to avoid a penalty

  • I am not a physician, physician assistant, nurse practitioner, or clinical nurse specialist. (Psychologists, social workers, and other non-physicians will likely be added in the future.)
  • I see no Medicare patients, or none enrolled in Part B. I only see patients through Medicaid, CHIP, private payers, and/or health insurance exchanges.
  • I see Medicare patients but my services are paid only through Medicare Advantage.
  • I have formally opted out of Medicare and see Medicare patients only under private arrangement.
  • This was the first year I enrolled in Medicare.
  • I (or my group practice) have no more than 200 Medicare Part B patients OR no more than $90,000 in Part B allowable charges per year (the MIPS "low-volume threshold").
  • I am a "qualifying participant" in an "advanced" alternative payment model (Advanced APM) or a "partially qualifying" participant and choose not to participate in MIPS.

YES, I do have to report to avoid a penalty (or earn a bonus)

  • I am a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and I (or my group practice) have over 200 Medicare Part B patients AND over $90,000 in Part B allowable charges per year. These include separate Part B payments/patients seen through federally qualified health centers (FQHCs) and rural health centers (RHCs).
  • I am a "partially qualifying" participant in an Advanced APM and I choose to participate in MIPS reporting. (Reporting any MIPS data means you will be assessed in all MIPS categories, and you could receive a positive –or negative– payment adjustment.)

In other words, under the MIPS "low-volume threshold," for the 2018 MIPS performance year:

  • You (or your practice) are EXEMPT from MIPS reporting and adjustments if you have no more than $90,000 in Medicare Part B allowed charges per year; OR you provide care for no more than 200 Part B enrolled beneficiaries per year.
  • You (or your practice) are SUBJECT to MIPS reporting requirements and payment adjustments ONLY if you annually bill Medicare Part B more than $90,000 AND you see more than 200 Medicare Part B patients per year.

If you practice in multiple settings — for example, you see patients in your solo practice as well as in a facility or group practice — you may be exempt for some settings but subject to MIPS for others. If you are unsure of your MIPS participation status, you can check your status using the CMS Lookup Tool. Enter your national provider identifier (NPI) to see your status. You may also have received a MIPS Participation/Exemption Letter indicating your status, from the Medicare Administrative Contractor that processes your claims. CMS allows clinicians who are not subject to MIPS requirements to submit MIPS data and receive a MIPS composite score. However, they cannot earn a MIPS bonus.

Step 2: When and How Can I Report for 2018?

There is no reporting for the MIPS Cost category. All 2018 MIPS data is due by March 31, 2019. Medicare claims (for claims-based Quality reporting) must be received by March 1, 2019. Reporting via the CMS Web Interface is due by March 16, 2019. MIPS reporting can be done via Medicare claims (for Quality only), electronic health records, qualified registry, or qualified clinical data registry (QCDR). PsychPRO, the APA mental health registry, is a QCDR. CMS recently added two new reporting options. First, small and solo practices (of up to 10 MIPS eligible clinicians) can form a voluntary "virtual group" to report and be assessed together, as a group. The deadline to sign up for 2018 was December 31, 2017.

Second, all types of MIPS data can be submitted using CMS's new online portal on the Quality Payment Program (QPP) website. You will need an Enterprise Identity Management (EIDM) account to submit data through the portal. If you need to set up an EIDM account, get EIDM account information, or reset your password on an existing EIDM account, visit the CMS Enterprise Portal. For questions, contact the Quality Payment Program at 1-866-288-8292. CMS has an EIDM Guide to help with this process.

Step 3: What Should I Report to Earn a MIPS Bonus in 2020?

To earn a bonus in 2020, you must report complete 2018 MIPs data for three MIPS categories, Quality, Improvement Activities (IA), and Advancing Care Information (ACI), and you may also be scored on the Cost category (by CMS). For 2018, the Quality category counts 50% of your total composite score; ACI counts 25%; IAs count 15%; and Cost counts 10%. The Quality and Cost performance period is the entire year, while the ACI and IA categories must be reported for 90 days. The highest regular MIPS bonus in 2020 is 5%. "Exceptional performers" scoring in the top 30% may earn an additional bonus of up to 10%. So eligible clinicians may receive a total bonus in 2020 of up to 15%.

Step 4: What is the Easiest Way to Do MIPS Reporting?

The easiest way to do future MIPS reporting is to join the APA's national mental health registry, PsychPRO, which CMS has approved as a qualified clinical data registry (QCDR). APA members can sign up for free by going to the Sign-up Portal. Once you are connected, PsychPRO collects your data and does your MIPS reporting for you. It is really that simple. You will earn credit in the Improvement Activities category just for participating in a QCDR, and you can choose from both MIPS quality measures, and non-MIPS QCDR quality measures approved by CMS.

Step 5: How Can I Report MIPS Quality Measures?

Quality counts 50% of your total composite score for the 2018 performance year. Quality measures can be reported via Medicare claims, EHR, QCDR, or qualified registry. Eligible clinicians are required to report six quality measures, including one outcome measure is one is available – or one measure of appropriate use, patient safety, efficiency, patient experience, or care coordination. Each measure must be reported for at least 60% of the patients to whom that measure applies. For claims reporting, this means 60% of your Medicare Part B patients. For other reporting, this means 60% of all of your patients, regardless of payor. The 2018 "Mental/Behavioral Health" measure set has 25 measures. The set, as well as 24 other recommended quality measures for psychiatrists, are included with the Quality Fact Sheet in the APA Payment Reform Toolkit.

Claims-Based Quality Reporting: If you choose to do claims-based reporting of MIPS quality measures, you must include your selected quality measure(s) when you file your Medicare claims. Here are some detailed instructions on how to do that:

  • Complete boxes 1 through 20 on your 1500 Medicare claims form as you normally would, including box 21, the patient’s diagnoses and procedure codes.
  • Find one or more MIPS quality measures by consulting the CMS search tool or the Quality Fact Sheet in the APA Payment Reform Toolkit. Write down the 3-digit quality ID number for each measure you would like to report.
  • Download the 2018 Quality Measure Specifications.
  • Using the quality ID number(s) you recorded in step 2, find the claims document for each measure you are reporting. rite down the Quality Data Code (QDC) for each measure.
  • On your 1500 claims form, enter the QDC code(s) in box 24D and one cent ($0.01) in box 24F.
  • Complete boxes 25 through 33 and submit your 1500 claims form to your Medicare Administrative Contractor (MAC).

Step 6: How Can I Report for Advancing Care Information (ACI)?

The ACI category counts 25% in your total MIPS composite score. In order to pass this category, a psychiatrist must either use certified electronic health record technology (CEHRT) or qualify for a hardship exception. The hardship exceptions for the 2018 performance year are: 1) insufficient internet connectivity; 2) extreme and uncontrollable circumstances (such as natural disasters); 3) lack of control over availability of CEHRT (including practicing in multiple sites or where there was no input in the selection of technology); 4) lack of face-to-face interaction (telepsychiatry is considered face-to-face); 5) hospital-based clinicians who furnish 75% or more of their services in inpatient or outpatient hospital settings; 6) clinicians whose CEHRT was "decertified" during the performance period or preceding year; and 7) clinicians in small practices (of up to 15 clinicians) facing "overwhelming barriers" to comply with ACI requirements. You must apply for a hardship exception, each year.

Psychiatrists who wish to report for the ACI category must report five measures to achieve a Base Score. Then they can earn points for reporting up to eight measures for their Performance Score. Bonus points are also given for certain MIPS Improvement Activities. More information is available in the Advancing Care Information Fact Sheet in the APA Payment Reform Toolkit.

Step 7: How Can I Report MIPS Improvement Activities?

This category counts 15% in your total MIPS composite score. There are 112 activities for 2018, including several "Integrated Behavioral and Mental Health" activities, such as collaborative care. All but a few must be done for at least 90 consecutive days. However, psychiatrists are likely to find several activities they already do as part of their practice. Forty points are generally required to achieve full credit. High-weighted activities count 20 points each, and medium-weighted activities count 10 points each. The requirements are lower for small and rural practices and those in health professional shortage areas (HPSAs). Participants in certain "MIPS alternative payment models," such as patient-centered medical homes and accountable care organizations, receive half or full credit in this category. You can "attest" to having performed activities through the CMS online portal on the QPP website. Or you can submit activities via a QCDR, qualified registry, or your electronic health record system. Groups of 25 or more may use the CMS Web Interface. You should keep supporting documentation for 6 years. More information is available in the Improvement Activities Fact Sheet in the APA Payment Reform Toolkit, including a list of activities recommended for psychiatrists.

Step 8: How Will CMS Calculate My Cost Score?

For the 2018 performance period, the Cost category will count 10% in your MIPS composite score. There is no specific reporting for this category, as it will be calculated by CMS. CMS will base its calculations on two cost measures: Medicare Spending per Beneficiary, and total per capita costs. However, there are minimum cases that must be reached for these measures to apply. So some psychiatrists may see this category weighted to zero. Future Medicare claims will need to include special codes indicating the care episode, patient condition, and relationship to the patient, to help attribute costs correctly to the appropriate clinicians. Psychiatrists should also be aware that in 2018, Medicare Part B payments to psychiatrists may be subject to VM bonuses or penalties. Fortunately, CMS lowered the penalties for 2018, and unsuccessful PQRS reporters no longer receive an automatic VM penalty. VM bonuses can range up to 2% for small practices (up to 10 physicians) and up to 4% (for larger practices). In the past, many physicians were considered "average" and did not receive any adjustment.

Step 9: Can I Earn Bonus Points?

Starting with the 2018 performance year (and 2020 payment adjustments), some eligible clinicians (and groups) can earn additional bonus points on their final MIPS composite score. Those in groups (or virtual groups) of fewer than 15 clinicians will earn five extra bonus points. Eligible clinicians (and groups) that treat complex patients with multiple conditions, and patients dually eligible for Medicare and Medicaid, can earn up to five extra bonus points, depending on the number of patients and severity of their conditions. The MIPS program allows bonus points for improvement over time. CMS is testing the waters by starting to reward improvement in the Quality category in performance year 2018.

What CMS resources are available?

What if I still have questions or issues regarding the MIPS ACI performance category?

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