Author: Emil Engels, MD, MBA, CPC
The Medicare Access and CHIP Reauthorization Act of 2015, or MACRA, shifts the Medicare payment base from volume to value. This landmark legislation aims to move Medicare from fee-for-service to a system that rewards quality and low cost. As recently as the summer of 2016, 50% of physicians had not heard of MACRA. In what can only be viewed as an accelerated timetable, even by government standards, the law passed in 2015 was followed by a final rule in 2016 and then implementation in 2017.
This change has created a state of “MACRA Madness.” Every medical meeting now has a talk on MACRA, and articles continue to proliferate in health care journals. Alarmist headlines include titles like “Thriving During the Zombie Apocalypse (a.k.a. MIPS).”1 Providers are overwhelmed by the amount of information out there, yet few articles offer practical information for anesthesia providers on how to participate.
The Republicans in Congress have talked of repealing and replacing the Affordable Care Act (Obamacare) and are in the process of doing so, and some are hopeful that MACRA might meet a similar fate. However, it is extraordinarily unlikely that this will happen, since the law was passed with overwhelming bipartisan and bicameral support. Dr. Tom Price, the secretary of the Department of Health and Human Services, has vocally opposed mandatory participation in some alternative payment models (APMs). Although he may soften or alter some of the rules associated with APMs, it is likely that MACRA will be the law of the land for many years to come. Providers will need to navigate the myriad of regulations to avoid penalties under the new system.
Where does this leave anesthesia providers in 2017? This latest article in a series on health care reform will provide practical tips on participating in MACRA this year and discusses the importance of being “non–patient-facing.”
At the 30,000-foot level, the MACRA law creates payment incentives to move the American health care system toward one that rewards value and penalizes poor quality and high cost. Providers have two pathways to participate: Advanced Alternative Payment Models or the Merit-Based Incentive Payment System (MIPS). If you have less than $30,000 in Medicare allowable charges or fewer than 100 Medicare patients, you are exempt from MACRA—good news for a minority of you. As discussed in previous articles in Anesthesiology News, most anesthesia providers will not be exempt and will participate via the MIPS pathway this year. The Centers for Medicare & Medicaid Services (CMS) mailed letters to providers regarding MACRA participation status in early May. In addition, you can look up whether or not you are required to participate at: https://qpp.cms.gov/?.
The MIPS system assigns a score to each provider on a 100-point scale. Four categories contribute to that score: Quality, Practice Improvement Activities, Resource Use (Cost) and Advancing Care Information (meaningful use). The cost category will not contribute to your score in 2017, because CMS is revising and refining it. Therefore, for most eligible professionals, the MIPS score will include a 60% contribution from quality, 15% from practice improvement activities and 25% from advancing care information.
How to Avoid a Penalty
In 2016, then–CMS acting administrator Andy Slavitt created some flexibility and leniency in requirements for this year. The “pick your pace” program allows providers to “submit something” to CMS in 2017 and avoid a negative payment adjustment in 2019. What does “submit something” mean? If a clinician submits one quality measure, or one performance improvement activity, or the four to five required advancing care information measures, then the assessment of a penalty is averted. The Quality Payment Program (QPP) help desk was asked to clarify the requirement to report one quality measure, and it supplied the following response:
“The minimum to report to avoid a negative payment adjustment is 1 measure, 1 time, for 1 patient.
“Example: Sally comes to your office today and you document her current medications (Quality measure #130), and report G8427 with your claim, you have submitted the Test option and will avoid the negative payment adjustment.”
The Benefit of Being ‘Non–Patient-Facing’
MACRA coined the term “non–patient-facing” to describe facility-based clinicians. The choice of wording is poor, because many facility-based clinicians such as anesthesiologists face the patient and have significant human interaction. Nonetheless, this term refers to a category of providers who receive favorable treatment under MACRA. The rationale is that facility-based clinicians lack substantial control over the electronic health record; performing practice improvement activities requires coordination with other stakeholders. Non–patient-facing clinicians are exempt from the advancing care information category. In addition, they have a lower reporting requirement for practice improvement activities. For example, a patient-facing clinician has to report on two high-weighted activities or four medium-weighted activities. A non–patient-facing clinician has half the burden—he needs only to report on one high-weighted or two medium-weighted practice improvement activities.
How is this status determined? CMS published a list of “patient-facing CPT [Current Procedural Terminology] codes.” This list looks very similar to the list published under the Physician Quality Reporting System (PQRS) that was used to determine “face-to-face” encounters. If a provider bills 100 or fewer patient-facing CPT codes, then he is non–patient-facing. If he bills more than 100 codes, he is patient-facing. The list of codes can be found at the quality payment program website: qpp.cms.gov. To find it, click on the “Education and Tools” tab. The list of patient-facing encounter codes can be found under the heading, “Quality Measure Encounter Codes.”
The list of codes does not include anesthesia CPT codes. However, the list does include evaluation and management (E & M) services, as well as many pain procedures. In addition, the list includes codes such as 31500 (intubation, endotracheal, emergency procedure) and 36556 (insertion of a central venous catheter, age 5 years or older).
I recommend that you ask your billing company to determine your status by comparing codes on the list of patient-facing encounters with historical billing data for your practice. At the time this article was written, CMS had not announced details on how or when it will notify providers regarding their status.
The Advantage of Reporting As a Group
MACRA also makes allowances for those individuals who choose to report as a group. For example, if you report as a group, and 75% of your group is non–patient-facing, then the group is considered non–patient-facing. This is advantageous for a group that has a mix of providers and a minority of pain physicians, since most pain physicians will be patient-facing. By reporting as a group in this situation, you can eliminate the requirement of your pain physicians to report the advancing care information category.
With the PQRS, a practice designated its desire to submit data as a group by registering with CMS. This was referred to as the “Group Practice Reporting Option (GPRO),” and required registration by June 30. Under MACRA, this process has changed. CMS will create a registration process in the future, but it does not exist to date. Instead, a qualified registry or Qualified Clinical Data Registry (QCDR) will need to indicate group status with the submission of data during the first quarter of 2018.
Are There Other Ways to Avoid the Requirement to Report the Advancing Care Information Category?
The good news for anesthesia providers is that most should be exempt from the advancing care information category. There are four ways to be exempt:
- Non–patient-facing clinicians do not have to report the advancing care information category.
- “Hospital-based clinicians” are also exempt. A hospital-based clinician is one who provides 75% of his services at Place of Service locations 21 (hospital inpatient), 22 (hospital outpatient) and 23 (emergency department). Note: Place of Service 24 (Ambulatory Surgical Center) and 19 (Off Campus-Outpatient Hospital) are not currently included in the definition.
- If you are a CRNA, you are automatically excluded from this category in 2017. The rationale is that CRNAs lack substantial control of the electronic health record. It is possible that CRNAs may need to report in future years.
- Providers can apply for a yearly hardship exemption. Anesthesiologists would seek an exception on the grounds that they lack control of the electronic health record. As of this writing, CMS has not published information on how to apply for the exemption. If interested, contact the Quality Payment Program’s help desk.
Where Does This Leave Most Anesthesia Providers for 2017?
The majority of anesthesia providers will be required to participate in MACRA and will do so via the MIPS pathway. To avoid a 4% penalty in 2019, one must “submit something” to CMS this year. This can be as little as one measure, one time, for one patient.
For those who want to partly or fully participate, it is likely that you will only need to submit data in two MIPS categories. The benefit of being non–patient-facing is stated above. As a result, most of you will be exempt from the advancing care information category, and the cost category will not be considered this year. Therefore, anesthesia providers likely will only report quality measures and practice improvement activities. In this situation, quality reporting will be counted as 85% of your score and practice improvement activities as 15%.
CMS has created significant flexibility for 2017 MACRA participation. All anesthesia providers should submit data to CMS to avoid the penalty. In addition, 2017 is a great year to test the waters and prepare for full participation in the future.
Look for future columns on other quality reporting topics.
Dr. Engels is an anesthesiologist with MEDNAX and can be reached at EmilEngelsMD@gmail.com
This column includes information from the Centers for Medicare & Medicaid Services and represents the author’s best interpretation of available resources. The author is not recommending specific methods for participating in MACRA. Providers who have questions should consult a compliance professional or contact the CMS Quality Payment Program Help Desk by sending an email to firstname.lastname@example.org.
- http://www.rcmanswers.net/?thriving-zombie-apocalypse-k-mips/?. Accessed May 8, 2017.