This Week: April 7, 2018

This Week in Washington, D.C.

  • 2 Important CMS Updates for GI Practices: Biosimilar Coding Changes and Medicare Appeals Guidance
  • Call to Action: ACG active on Step Therapy bills at state and federal level. New bill just introduced in Minnesota!
  • MACRA Tidbit for the Week: The MIPS Advancing Care Information performance category: Breaking down the complexity

From ACG Practice Management Committee Chair, Louis J. Wilson, MD, FACG

2 Important CMS Updates for GI Practices: Biosimilar Coding Changes and Medicare Appeals Guidance

Medicare Part B Biosimilar Payment and Required New Codes: Dates of Service on or after April 1, 2018

Pursuant to a recent CMS update, the “Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes – April 2018,” please note that there is a coding change when administering the biosimilar of infliximab.  HCPCS Q5102 will be replaced with two codes: Q5103 and Q5104, effective this month.  According to CMS, the new biosimilar payment policy makes unnecessary use of the modifiers that describe the manufacturer of a biosimilar product.  Effective for Medicare Part B claims with dates of service on or after April 1, 2018, ACG members need to use the two biosimilars codes noted below:

  • Q5103: Injection, infliximab-dyyb, biosimilar, (inflectra), 10 mg
  • Q5104: Injection, infliximab-abda, biosimilar, (renflexis), 10 mg

Read the CMS Transmittal guidance here

Please note: HCPCS code Q5102 and the requirement to use biosimilar modifiers remain in effect for dates of service prior to April 1, 2018.

Medicare Part B Appeal Process: CMS Releases Revised Guidance

CMS also revised guidance to assist ACG members and GI practices when considering to appeal to a recent Medicare Part B reimbursement denial or coverage decision.  Please see the revised guidance here.

CMS breaks the guidance down through the 5 levels of the appeals process, and also provides helpful tips throughout each step: read the full blog here.


Call to Action:
ACG active on Step Therapy bills at state and federal level
New bill just introduced in Minnesota!

Please contact Congress on a very important patient advocacy and practice management issue.  ACG has focused efforts to limit insurer “Step Therapy” requirements at both the federal and state level.  Step Therapy entails the “fail first” drug therapy requirements, in which patients are forced by insurers to try and fail with one or more medications before the insurer approves the cost of the medication which ACG members originally prescribed.  Representative Brad Wenstrup (R-OH) has introduced the “Restoring the Patient’s Voice Act of 2017” (HR 2077), which allows for exemptions for Step Therapy requirements in health plans regulated by federal law.

To help make an impact, your legislators need to hear from you directly, and the ACG website makes this process quick and simple.  Use the link below to advocate your support.

All ACG members: click here to take action now!

ACG Governors and members continue to express their frustration over the amount of time and resources GI practices spend dealing with insurers and prior authorizations, at the detriment to patient care. These policies are not rooted in clinical evidence, and ultimately take valuable time away from treating patients.  ACG continues to stress the importance of protecting the sanctity of the patient-physician relationship.  Results from a December 2017 survey of 1,000 practicing physicians show the negative effect of Prior Authorizations:

  • Physician practices continue to wait for an answer from insurers: 64% reported waiting at least 1 day for Prior Authorization decisions from health plans, while 30% reported waiting at least 3 business days.
  • These wait times translate into patient care delays: 92% of physicians saying that Prior Authorization delays access to necessary care, and have a negative impact on patient clinical outcomes.
  • These delays have serious implications for patients: 78% of physicians reported that Prior Authorizations can lead to treatment abandonment.

The survey also addressed the burdens imposed on physician practices:

  • Physician practices complete an average of 29 Prior Authorizations per week, per physician.
  • This workload requires 14.6 hours —nearly two business days per week— of physician and staff time, and time away from patients.
  • 84% of physicians characterized Prior Authorization-related burdens as high or extremely high. 86% of physicians reporting that PA burdens have increased over the past 5 years.

ACG Members in Minnesota: Urge your state legislators to support the “Step Therapy Override” bills (SF.2897 and HF.3196), recently introduced in both the House and Senate, by State Representative Kelly Fenton and State Senator Paul Utke.  These bills set certain requirements for insurers when establishing step therapy protocols, and require insurers to allow for a convenient and transparent process to override any step therapy protocols under certain scenarios.

ACG members in Minnesota: click here to take action now!

The MIPS Advancing Care Information performance category:
Breaking down the complexity

This category is similar to the “Meaningful Use” Program.  However, CMS is attempting to reduce practice management burdens by focusing more on health IT functionality (what the EHR can do) and interoperability (who the EHR can communicate with).  The Advancing Care Information (ACI) MIPS performance category makes up 25% of total MIPS score in 2018.

Remember: each MIPS performance category has its own scoring system. You need to fulfill the requirements of all the “Base Score” measures. If these requirements are not met, you will get a 0 in the overall Advancing Care Information performance category score.…. this category is still related to Meaningful Use, so it has to be a bit more complicated, right?

Of course.  But ACG will try to simplify this for you.

Here’s how it works:

The first complicating factor: the measures you report depend on the type of certified health IT your practice has and when it was certified.  Don’t know what year your CEHRT is certified?  Click here.

Click here for the requirements and ways to submit each ACI measure.

2014 vs. 2015 CEHRT: The fork in the road

There are different Advancing Care Information Measure Sets depending on the year in which your EHR system was certified by CMS.

MIPS-eligible clinicians can report the “Advancing Care Information objectives and measures” if you have:

Health IT that CMS has certified in the 2015 Edition; or

MIPS-eligible clinicians can alternatively report the “Advancing Care Information transition objectives and measures” if you have:

Health IT that CMS has certified in the 2015 Edition; or

The 2018 “Advancing Care Information Objectives and Measures” Set

The 2018 “Advancing Care Information Transition Objectives and Measures” Set

The 2018 “Advancing Care Information Objectives and Measures” Set Bonuses (the 2018 ACI Measure, how much it is worth? What do I report?)

The 2018 “Advancing Care Information Transition Objectives and Measures” Set Bonuses (the 2018 ACI Measure, how much it is worth? What do I report?)

Advancing Care Information Scoring (Base Score + Performance Score + Bonuses)

For the ACI performance category, you could actually score above 100% for this specific category, but it will be capped at 100%.  This structure was deliberately created by CMS to “ensure that clinicians have flexibility to focus on measures that are the most relevant to them and their practices.”

How is the Base Score Calculated?

MIPS-eligible clinicians need to fulfill the requirements of all the “base score” measures in order to receive the 50% base score. The base score is necessary– if these requirements are not met, you will get a 0 in the overall Advancing Care Information performance category score.

In order to receive the 50% base score, MIPS-eligible clinicians must submit a “yes” for the security risk analysis measure, and at least 1 patient in the numerator for the numerator/denominator of the remaining measures.  The “good news” is that some of the base score measures can also contribute towards your Performance Score.

Key Takeaway: All you need is 1 patient to get the full credit for a required measure.

How is the Performance Score Calculated?

The “Performance Score” is calculated by looking at the numerators and denominators submitted for each measure.  Think of “performance” as the number of patients you report that are applicable to that particular measure.  Do not confuse patient health-outcomes performance with measure reporting performance.

For each measure with a numerator/denominator, the percentage score is determined by the “performance rate.” Example: if you submit a numerator and denominator of 85/100 relevant patients, your performance rate would be 85%, and they would earn 9 percentage points for that specific ACI measure.

Performance Rates for Each Measure When Worth up to 10%
Performance Rate 1-10 = 1% Performance Rate 51-60 = 6%
Performance Rate 11-20 = 2% Performance Rate 61-70 = 7%
Performance Rate 21-30 = 3% Performance Rate 71-80 = 8%
Performance Rate 31-40 = 4% Performance Rate 81-90 = 9%
Performance Rate 41-50 = 5% Performance Rate 91 – 100 = 10%

**There are 2 measures with a Performance Score worth up to 20%.  You would use the same chart above, but multiply by 2.

Advancing Care Information Scoring: Two Real World Examples

Example 1:

A solo practitioner reports all objectives and measures of the base score, but did not report any measures toward the performance score.  The clinician would receive 50 points for the Advancing Care Information performance category, which would then be weighted 25% of the total MIPS score.

(5 measures X 10%) + (0 measure X 10%) or 50 out of 100 possible points, or 50/100 X 25 (weight of the Advancing Care Information MIPS performance category) = 12.5 points toward the total MIPS score.

Example 2:

A group’s EHR technology was certified to the 2015 Edition.  They report all objectives and measures of the base score.  They also report 6 measures in the performance score with a 100% performance rate.  They also attest to using a clinical or specialized registry such as GIQuIC.  The group would earn 125 percentage points toward the Advancing Care Information performance category.  Because a clinician or group cannot exceed 100 percentage points, the score would be reduced to 100%, which would then be weighted at 25% of the total score.

(5 measures X 10%) + (6 measures X 10%) + (15% bonus) or 125 out of 100 possible points, or 100/100 X 25 (weight of the Advancing Care Information MIPS performance category) = 25 points toward the total MIPS score.

Advancing Care Information: Hardship Exemptions and Exclusions

You can still claim a hardship exemption for this performance category like you could under the old Meaningful Use program.  A MIPS-eligible clinician or group may submit a “Quality Payment Program Hardship Exception Application,” citing one of the following specified reasons.

Important: Know the status of clinicians in your practice! “Special Status Clinicians”

There are some MIPS-eligible clinicians that are considered “Special Status,” who will be automatically reweighted and do not need to submit a Quality Payment Program Hardship Exception Application.  Special Status clinicians include the following.

MAKING $ENSE OF MACRA

CMS….SGR… MACRA… MIPS… APMs… QCDRs… ACOs… Why does Washington D.C. love acronyms and complicated payment systems?  What the heck is going on here?  ACG Hopes to Keep This Simple.   We compiled a detailed overview for you that seeks to make some sense out of this alphabet soup – but hopefully in a simplified fashion and in plain English.  Read the summary and potential impact to GI.

Dissecting MACRA:
Year 2