ACP American College of Physicians - Internal Medicine - Doctors for Adults

Medicare Electronic Prescribing (eRx) Incentive and Payment Adjustment (Penalty) Program

The Medicare eRx incentive and payment program encourages physicians and other healthcare professionals to implement and use electronic prescribing technology. The program employs a combination of incentives for required implementation and use and penalties for failure to implement. There are defined exemptions and hardship exceptions.

Physician Quality Reporting System (PQRS)

PQRS is a program from the Centers for Medicare and Medicaid Services (CMS) that uses a combination of incentive payments and payment adjustments to promote reporting of quality information by eligible professionals. The program provides an incentive payment to practices with eligible professionals (identified on claims by their individual National Provider Identifier [NPI] and Tax Identification Number [TIN]) who satisfactorily report data on quality measures for covered Physician Fee Schedule (PFS) services furnished to Medicare Part B Fee-for-Service (FFS) beneficiaries.

Beginning in 2015, the program applies a payment adjustment to eligible professionals who do not satisfactorily report data on quality measures for covered professional services.

Meaningful Use

The Medicare and Medicaid EHR Incentive Programs provide incentive payments to eligible professionals, eligible hospitals and critical access hospitals (CAHs) as they adopt, implement, upgrade or demonstrate meaningful use of certified EHR technology. Eligible professionals (EPs) can receive up to $39,000 for those starting in 2013, through the Medicare EHR Incentive Program and up to $63,750 through the Medicaid EHR Incentive Program. In order to receive the full incentive, the EP must successfully report for five consecutive years.

Beginning in 2015, Medicare eligible professionals who do not successfully demonstrate meaningful use will be subject to a payment adjustment. The payment reduction starts at 1% and increases each year that a Medicare eligible professional does not demonstrate meaningful use, to a maximum of 5%.

In order to avoid the payment adjustment for a particular year, an EP must successfully demonstrate meaningful use during the calendar year two years earlier. There is a special exception for the first year of the adjustment program. In order to avoid an adjustment for 2015, an EP must successfully demonstrate meaningful use by October 1, 2014.

Value-Based Payment Program (VBP)

VBP is a program from the Centers for Medicare and Medicaid Services (CMS) that will adjust physician payments according to quality and cost data. The program is mandated by the Affordable Care Act (ACA) and intends to provide comparative performance information to physicians as part of Medicare's efforts to improve the quality and efficiency of medical care. In the initial phase, quality and cost will be measured during the performance year 2013, and payments will be adjusted in 2015 to groups with 100 or more eligible professionals (EPs).

ICD-10

The International Classification of Diseases, 10th Edition, Clinical Modification (ICD-10-CM) is designated, under HIPAA requirements, as the U.S. replacement for an earlier version of the standardized, healthcare diagnosis code set, ICD-9. ICD-10-CM will be implemented in 2014. Physician practices must be fully compliant with ICD-10 coding no later than October 1, 2014.

Physician Payment Sunshine Act

The National Physician Payment Transparency Program: Open Payments, also known as the "Physician Payment Sunshine Act" requires:

1. Applicable manufacturers of drugs, devices, biologicals, or medical supplies covered by Medicare, Medicaid or the Children's Health Insurance Program (CHIP) to report annually certain payments or transfers of value provided to physicians or teaching hospitals ("referred to as covered recipients").

2. Applicable manufacturers and applicable group purchasing organizations (GPOs) to report annually certain physician ownership or investment interests.

3. Publication of applicable manufacturers' and applicable GPOs' submitted payment and ownership information on a public website.

Covered recipients and physicians with certain ownership and investment interest will be provided with at least a 45 day period in which to review, correct or dispute the information provided by applicable manufacturers and GPOs.

TCM Codes

The 2013 Medicare Physician Fee Schedule includes transitional care management (TCM) codes that allow for reimbursement of the non-face-to-face care provided when patients transition from an inpatient, acure care setting back into the community. Two new codes will be used to bundle payment for a face-to-face visit and many of the non-face-to-face services that, up until now, were done but not reimbursed.

CPT Code 99495 covers communication with the patient or caregiver within two business days of discharge. This can be done by phone, e-mail, or in person. It also involves medical decision making of at least moderate complexity and a face-to-face visit within 14 days after the inpatient facility discharge. The location of the face-to-face visit is not specified. The work RVU is 2.11.

CPT Code 99496 covers communication with the patient or caregiver within two business days of discharge. This can be done by phone, e-mail, or in person. It also involves medical decision making of high complexity and a face-to-face visit within seven days of discharge. The location of the face-to-face visit is not specified. The work RVU is 3.05.

Below is a suggested timeframe to consider when using these codes:

• Day 1: Patient is discharged from inpatient facility.
• Day 1-2: Determine whether the practice will assume primary care responsibilities for the patient.
• Day 2-3: Contact the patient regarding the discharge summary and immediate care plan.
• Day 3-6: Determine whether the patient's condition requires a face-to-face visit, and whether it should occur within 7 or 14 days of the discharge date. Schedule the face-to-face visit.
• Day 3-30: Provide non-face-to-face care management (refer to list of physician/clinical staff activities).
• Day 30: Bill CPT code 99495 or 99496.