This Week – June 18, 2016

This Week in Washington, D.C.

  • ACG’s MACRA Tidbit for the Week
  • USPSTF updates recommendations on colorectal cancer screening


The “Resource Use” MIPS Component:

Will gastroenterologists use a different polyp-removal technique?
Should you send some E&M requests to voicemail?

Background: Resource Use = Costs from Medicare Claims

The “Resource Use” MIPS category is somewhat similar to the current value-based payment modifier, where CMS looks at claims data at the practice level to determine whether group practices are cost-efficient compared to other providers.  Under MIPS, however, CMS will perform this review at the individual provider level as well.  Performance in this category is assessed through your Medicare claims data.   Providers will not be required to submit additional data for this MIPS category.

Determining your score: In addition to two measures carried over from the value-based payment modifier (Total per costs capita for all attributed beneficiaries and Medicare Spending per Beneficiaries (MSPB) CMS is also proposing GI “episodes of care.”  An “episode” is defined as a window of care that is triggered by a certain CPT or diagnosis code, then lasts a period of time after that trigger code (i.e. 30-90 days).  For GI, CMS proposes to use Medicare claims for cholecystitis, Clostridium difficile colitis, diverticulitis of the colon, and/or colonoscopy with biopsy.  CMS will “attribute” the costs to a provider based on the NPI on the Medicare claims form.  These costs will help determine the provider’s individual Resource Use score.  The score will be calculated based on the comparison from the average or median “benchmark score” for each episode CMS calculates from the other providers.

According to CMS, “We propose that for resource use measures, lower costs represent better performance.”  This means that low cost translates into a higher Resource Use MIPS score.

A provider’s Resource Use score will be 10% of a total composite MIPS score in 2019, 15% of a total composite score in 2020, and 30% of a total composite score in 2021.  CMS proposes a 20 patient minimum sample for each provider and 10 points for each applicable measure.

The Potential Resource Use Problem: Stuck between a rock and hard place?

The lower the costs attributed to the provider, the higher your Resource Use score.  This will be very important after 2021 when Resource Use reflects 30% of your total MIPS score (thus reimbursement).  But will this have an unintended consequence on patient care?  How will this play out in actual practice?

For example, the “colonoscopy with biopsy” episode will be triggered by certain colonoscopy polyp removal CPT codes.  As CMS begins to assess your costs versus others in this episode, should ACG members think about using a lower RVU/reimbursement polyp-removal “trigger code” in order to mitigate the attributed costs?  Polyp removal via hot biopsy forceps over snare technique?  That may help you from a MIPS standpoint, and potentially on overall Medicare reimbursement especially after 2021.  But what if your facility or practice uses the RVU-based system to determine your salary?

Also, the triggered codes for the “Clostridium difficile colitis” and “diverticulitis of the colon” episodes include E&M codes within 30 days with a secondary or primary diagnosis of these illnesses.  CMS proposes to use the minimum of 20 cases for all of these episode-based measures.  Thus, if you keep getting calls for these services, should you consider limiting the number of E&M visits that could trigger the “Clostridium difficile colitis” and “diverticulitis of the colon” episodes attributed to you?  If not, then are you at risk of being unfairly labeled as a “high cost” provider by Medicare and your facility simply by responding to requests for an E&M service?

More on MACRA: ACG Hopes to Keep This Simple.   We compiled a detailed overview for you, hopefully in a simplified fashion and in plain English.  Read the summary and potential impact to GI: Making $ense of MACRA

The 2016 ACG Annual Scientific Meeting and Postgraduate Course will also delve into the details of these changes, as well as offer strategies and insight on how to adequately prepare your practice for these upcoming changes.

USPSTF Updates Recommendations on
Colorectal Cancer Screening

United States Preventive Services Task Force (USPSTF) finalized recommendations on colorectal cancer screening on June 15th. The USPSTF maintained its ‘A rating’ for colorectal cancer screening from ages 50-75, but unlike its 2008 recommendations, did not provide a specific grade for each screening modality.

The College’s colorectal cancer screening guidelines make the distinction between screening strategies that prevent colorectal cancer versus strategies that detect colorectal cancer. This distinction is in alignment with the guidelines of the U.S. Multi-Society Task Force on Colorectal Cancer.  ACG prioritizes colorectal cancer prevention over colorectal cancer detection and therefore recommends colonoscopy as the preferred colorectal cancer prevention strategy.

The success of the public health strategy for colorectal cancer screening depends upon a continuum of patient adherence and follow-up colonoscopy for any positive finding on other tests.

Read the full USPSTF Recommendations here.