Illinois & Wisconsin Chapter: Proposed Fee schedule Getting ready for 2019

Transcription

1 Illinois & Wisconsin Chapter: Proposed Fee schedule Getting ready for 2019 Cathleen Biga President/CEO Cardiovascular Management of Illinois

2 "The nine most terrifying words in the English language are: I'm from the government and I'm here to help." Timeline Ronald Reagan

3 PFS Highlights Rules released 7/12/18 ACC commented 9/10/18 Final rule will be out --- Trick or Treat Conversion Factor increases to $36.06 ($35.99)

4 Key elements Changes to E&M Changes to 25 Modifier Increased uses for telehealth/ communication strategies AUC mandate

5 E & M changes: aka Patients over Paperwork Reduced Administrative burden thank you Consults: bundling Levels 2-5 into 1 Level paid at $135 Established patients: Level 1 and Level all others paid at $93 Eliminates the prohibition on practitioners in the same group billing E&M on the same day 4 methods for documentation: Time, 95 guidelines, 97 guidelines, and Medical decision making

6 E/M Proposal Financial Impact

7 Prolonged Services There are 3 Prolonged Services: Office or outpatient Face to Face - 1 hour beyond normal services + q 30 min Same day E&M Physician or APP Prolonged Service: Inpatient Face to Face 1 hour beyond normal + 30 min. Same Day E&M Physician or APP

8 Prolonged Service w/o Direct Patient Contact Effective 1/1/ Prolonged evaluation and management service before and/or after direct patient care; first hour ** actually billed for the first 30 to 74 minutes each additional 30 minutes(list separately in addition to code for prolonged service) Prolonged service less than 30 minutes not separately reported This service can be reported for a different date than the primary service Cannot be reported during same service period as Chronic Care Management or Transitional Care Management Services

9 Prolonged service w/o face to face

10 Examples of non F2F Prolonged Services Billing Application of codes: 1. Provider spends 45 minutes reviewing extensive medical records the day after the patient visit. Total time spent = 45 minutes, report Provider spends 35 minutes speaking to another physician on the phone about transfer of patient care and 45 minutes doing an extensive review of the patient s records. Total time spent = 1 hr and 20 minutes, report and Provider spends 15 minutes in the morning discussing patient s care with another physician and 40 minutes in the afternoon reviewing the patient s records from another facility. Total time spent = 55 minutes, report

11 Doctor Note 1. Open a new encounter in the EMR 2. Select Patient Communication as the Visit Type 3. Click on the Doctor Note tab 4. Open the Doctor Note and document prolonged services with time, dates and activities 5. Check the Dr Signed box and click Accept 6. Click on Create Document 7. Click on the Fee Ticket and submit charge for Prolonged Services

12 New Code For Prolonged Service Add on To E/M Proposing A new code to add-on to any office visit lasting more than 30 minutes beyond the office visit (i.e., hour long visits in total). GPRO1 Prolonged evaluation and management or psychotherapy services(s) (List separately in addition to code for office or other outpatient Evaluation and Management or psychotherapy service) Will have a payment rate of $67 (1.85 wrvu s) Example: A cardiologist currently reporting a and spending more than 60 minutes with a patient would be paid $211. Under the proposed new method, the cardiologist would report: , depending on their documentation selection, - $135 GCG0X specialty add on - $14 GPRO1 prolonged service $67 Total combined payment of $215.

13 What is normal time New Patient Visit Typical Time (minutes) Establish ed Patient Visit Typical Time (minutes)

14 Issues Questions How many of our visits last 60 minutes 95 or 97 guidelines Should help with cloning audits Medical Decision Making Medical necessity of a Level 2 is required Will this facilitate team based care? How will it impact risk scores? MIPS Mortality

15 25 Modifier..aka E/M MPPR Used in conjunction with another service on same day Imperative to know your MAC rules: do they require it with an EKG on same day? Echo? Device Check? Immunization? Reduction of 50% of the least expensive procedure or visit provided by same TIN w identifiable E&M

16 Practice Expense Proposal Impacts ultrasound and vascular Reframes cost of our ultrasound rooms Reduces the general ultrasound room price by 65% (from $369,945 to $130,253) Results in a 9% reduction in payment - OFFICE

17 PE proposed changes Office imaging

18 Tele-Health Still need to meet the main geographical rules Remote monitoring (RPM) of physiological parameters RPM is outside tele-health requirements New codes for interpersonal internet consultation 6 codes Imperative to understand your patient flow

19 AUC mandate Voluntary 7/18 through 12/19 Effective 1/1/20 for a year of education must be reported on both tech and pro bill if split billing Providers must Will include consult IDTF s, will AUC implement via a G qualified codes, clinical and will allow non-physicians to consult AUC decision support mechanism both ordering and rendering what if you are interpreting only? Will include IDTF s Will implement G codes, and will allow nonphysicians to consult AUC

20 This and that Section 603 off-campus PBD: 40% payment factor remains Shared Decision making for specific ICD implants Placement and removal of loop recorders (1.53 and 1.50 wrvus) SET for PAD

21 HOPPS: PROPOSALS FOR 2019

22 Proposed OPPS Site neutrality becoming a common theme: $46 for off-campus G0463 $115 for on campus G0463 Exceptions to 603 clinical families of services 19 clinical families Comments requested for using prior auth for offcampus HOPD s Addition of 12 cardiac cath codes to approved ASC s Cardiac MRI: & watch APC classification: 15% reduction

23 Proposed Additions to ASC

24 OBL vs ASC for PAD

25 QPP: MIPS PROPOSALS FOR 2019

26 Yesterday s results..and Today s

27 2019 Overview Start with 2018: Scores recalculated Costs released for education 435,000 clinicians took the penalty in 2018 based on 2016 data (<3 points) PROPOSED: 2019: Quality 45% and 12 months Cost: 15% - 12 months; 10 episodes IA: 15% and 90 days MU/ACI/Promoting Interoperability: 25% and 90 days

28 2017 Data Cost Detail

29 MSPB: 2017 MSPB Cost

30 2017: TC TPCC Cost Detail

31 Currently 10 Episodes 3-4 for cardiology

32 Episodes for 2019 data Elective Outpatient PCI Cost Measure: Summary Results Understanding Your Cost Measure Score No Data Click here to provide feedback on the report With a total of 121 episodes for this cost measure: Your overall risk-adjusted cost measure The national average risk-adjusted cost measure score is: $11,137 $10,902 score is: And your cost measure score is 2% higher than the national average No Data No Data No Data STEMI with PCI Cost Measure: Summary Results Understanding Your Cost Measure Score No Data Click here to provide feedback on the report Breakdown of Part B Physician/Supplier Episode Cost by Your TIN vs. Other TINs The table and pie charts below show the breakdown of the average share of cost per episode where the source of Part B Physician/Supplier costs is the attributed clinician's TIN versus other TINs. This is presented for your TIN and for all TINs nationally (including your TIN). Below, the pie chart on the left presents the values for this breakdown for the average share of cost per episode for your TIN. The pie chart on the right presents the same values for all TINs nationally. With a total of 10 episodes for this cost measure: Your overall risk-adjusted cost measure The national average risk-adjusted cost measure score is: $17,245 $19,320 score is: No Data No Data Average Share of Cost Per Episode for Your TIN Average Share of Cost Per Episode for All TINs Nationally And your cost measure score is 11% lower than the national average No Data No Data Source of Part B Physician/Supplier Cost During Episode Average Share of Cost Per Episode Your TIN All TINs Nationally 5% No Data 6% Breakdown of Part B Physician/Supplier Episode Cost by Your TIN vs. Other TINs The table and pie charts below show the breakdown of the average share of cost per episode where the source of Part B Physician/Supplier costs is the attributed clinician's TIN versus other TINs. This is presented for your TIN and for all TINs nationally (including your TIN). Below, the pie chart on the left presents the values for this breakdown for the average share of cost per episode for your TIN. The pie chart on the right presents the same values for all TINs nationally. From Providers in the Attributed Clinician's TIN 95% 94% From Providers in a Different TIN 5% 6% Breakdown of Utilization and Cost by Selected Clinical Theme No Data 95% From Providers in the Attributed Clinician's TIN From Providers in a Different TIN 94% From Providers in the Attributed Clinician's TIN From Providers in a Different TIN Source of Part B Physician/Supplier Cost During Episode From Providers in the Attributed Clinician's TIN No Data Average Share of Cost Per Episode Your TIN All TINs Nationally 59% 51% Average Share of Cost Per Episode for Your TIN 41% No Data 59% No Data Average Share of Cost Per Episode for All TINs Nationally 49% 51% From Providers in a Different TIN 41% 49% From Providers in the Attributed Clinician's TIN From Providers in a Different TIN From Providers in the Attributed Clinician's TIN From Providers in a Different TIN

33 Key proposed changes for 2019 Will need 30 points for threshold Exceptional performance will be > 80 points ($500M available) Payment adjustment to 7% MUST have 2015-certified EHR (only 66% are in compliance) Claims data is on the hook in the future may be only available to small groups Watch your quality benchmarked No benchmark only 3 points

34 Getting ready for 2020 New Field Tested Reports just released In addition to the 8 added 10 (CABG and COPD) Educational in purpose Covers calendar year 2017 Attribution has changed MSPB and Total cost and new episodes Total cost/attributed beneficiary Detail available but format is different Gives you your %tile ranking

35 Getting ready for 2020 Attribution changes TPCC: much higher attribution rates 2 step attribution process is proposed to sunset MSPB: provides 30% of E&M or perform the episodic procedure Adds any clinician within the TIN who does any E&M

36 Medicare Spend/Beneficiary

37 Total per capita cost

38 Measure or Sub-Group Name Episodes Inpatient COPD Exacerbation Cost Measure: Results Click here to provide feedback on the report Understanding Your Cost Measure Score No Data With a total of 40 episodes for this cost measure: Your overall risk-adjusted cost measure score is: $13,597 image of multiple people to indicate your TIN The national average risk-adjusted cost measure score is: $13,477 This cell includes an image No Data And your cost measure score is 1% higher than the national average Table 1. Breakdown of Cost Measure Score by Episode Sub-Group Breakdown of Cost Measure Score by Episode Sub-Group Cost Measure Score Episode Count for Your TIN Name Short Form Name Your TIN National Average Percent Difference Between Your TIN's Average Risk-Adjusted Episode Cost and National Average Risk- Adjusted Episode Cost No Data Percent Difference Between Your TIN's Average Risk-Adjusted Episode Cost and National Average Risk-Adjusted Episode Cost Less Cost to Medicare National Average More Cost to Medicare Inpatient Chronic Obstructive Pulmonary Disease (COPD) Exacerbation ip_copd 40 $13,597 $13,477 1% 1% ip_copd COPD Exacerbation with Mechanical Ventilation > 24 hours mv_great_24 1 $25,484 $33,347-24% -24% mv_great_24 COPD Exacerbation with no Mechanical Ventilation or Mechanical Ventilation < 24 hours mv_less_24 39 $12,787 $12,599 1% The chart above presents the performance of your TIN relative to the national average for each of the episode sub-groups comprising this episode-based cost measure. An episode sub-group is a division of a cost measure s episode group that defines more homogenous patient cohorts to ensure clinical comparability (i.e., the cost measure fairly compares like patients). Specifically, for the cost measure and each episode sub-group, it displays the percent difference between your TIN's average risk-adjusted episode cost to Medicare and the national average risk-adjusted cost to Medicare. Negative values indicate that your TIN represents a lower cost to Medicare than the national average, and positive values indicate that your TIN represents a higher cost to Medicare than the national average. -120% -90% -60% -30% 0% 30% 60% 90% 120% + 1% Value mv_less_24 chart, there are two arrows that indicate how the values for this metric represent either less cost to Medicare (i.e., negative values) or more +

39 Table 3. Breakdown of Episode Cost by Your TIN vs. Other TINs Source of Cost During Episode Your TIN Average Share of Cost Per Episode National Average TINs in Your Risk Bracket Average Share of Cost Per Episode for Your TIN 32% 5% No Data Average Share of Cost Per Episode for the National Average 20% 6% Services Provided By Clinicians Under Your TIN 5% 6% 6% Services Associated with Clinicians Under Your TIN 62% 74% 74% 62% Services Provided By Clinicians Under Your TIN 74% Services Provided By Clinicians Under Your TIN All Other Services 32% 20% 20% Services Associated with Clinicians Under Your TIN Services Associated with Clinicians Under Your TIN All Other Services All Other Services inicians Under Your TIN, (2) Services Associated with Clinicians Under Your TIans Under Your TIN, (2) Services Associated with Clinicians Under You No Data Table 4. Breakdown of Utilization and Cost by Selected Clinical Theme Clinical Theme Your Average Cost Per Episode Percent Difference in Average Cost of Clinical Theme Services for Your TIN Versus TINs in Your Risk Bracket Share of Episodes with Any Cost From Given Clinical Theme Your TIN National Average TINs in Your Risk Bracket (1) Physical Therapy / DME $218-4% 62.5% 60.5% 61.1% (2) Bronchoscopy $0-100% 0.0% 0.4% 0.4% (3) Post-Acute Care $3,171 22% 35.0% 38.2% 38.5% (4) COPD Exacerbation $673-35% 67.5% 62.4% 63.7% (5) Pulmonary Complications, Other $357-38% 50.0% 58.1% 57.5% (6) Renal Failure and Metabolic Abnormalities $0-100% 0.0% 1.5% 1.4% (7) Cardiac Complications $21-76% 22.5% 15.8% 15.6% (8) Diabetic Complications $0-100% 0.0% 0.8% 0.8% (9) Sepsis $0-100% 0.0% 1.0% 0.9% (10) Thromboembolism (DVT/PE) $7-54% 2.5% 1.1% 1.2%

40 Current state 427 ACO s in received $799M of savings 16 of the MSSP Tracks 2 & 3 paid penalties of $57M Total savings across all the MSSP s = $313.7M

41 ACO update Proposed rules out comments complete No new APM s forthcoming Significant changes proposed 2 Tracks: Basic & Enhanced 5 yr. plans Basic: glide path from one-sided to 2-sided risk Plans A-E and E qualifies as a QAPM Lower shared savings 25% vs current 50% Enhanced: QAPM and mirrors MSSP Track 3

42 Do ACO s work?? Savings equaled $36/beneficiary 9 million patients enrolled We are in the 5 th year what have we learned? Those in down-side risk saved less There were 39 ACO s and they saved $27/beneficiary Will these new rules help?

43 Questions?