Physician & Practice Timeline®

The Timeline is a helpful summary of upcoming important dates related to a variety of regulatory, payment, and delivery system changes and requirements. Check back regularly for updated information.

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ABIM Maintenance of Certification Process

ABIM has announced changes to the Maintenance of Certification (MOC) process for board certified internal medicine specialists and subspecialists, effective January 2014. Beginning in 2014, ABIM will report two credentials for board-certified internists: whether you are Board Certified, and whether you are Meeting MOC Requirements. If you are not sure how the changes will affect you, check out the details at the ABIM website. The ABIM MOC requirements vary slightly depending on when your current internal medicine or subspecialty certification expires. Keep in mind that the same MOC points can apply to each certificate you renew; for example, internal medicine and a subspecialty certificate. In other words, you only need to earn 100 points no matter how many certificates you renew.

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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.

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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 (EPs). 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 EPs who do not satisfactorily report data on quality measures for covered professional services.

The deadlines for submitting 2015 PQRS data are now available for the following submission methods: EHR Direct or Data Submission Vendor (QRDA I or III); Qualified clinical data registries (QCDRs) (QRDA III); Group practice reporting option (GPRO) Web Interface; Qualified registries (Registry XML); and QCDRs (QCDR XML). Specific dates for each type of submission are outlined in the timeline.

Special Webcast: The Council of Medical Specialty Societies (CMSS) provided a free webcast about 2015 PQRS reporting via PQRSwizard. A live question and answer session immediately follows the presentation. View here.

CMS Reporting Methods:

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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.

First-Time Participants in 2016: For those participating in the program for the first time in 2016 - in order to avoid an adjustment in 2017, the first-time participant must successfully attest to any 90-day continuous period in 2016 by October 1, 2016. New participants who successfully demonstrate meaningful use for 2016 and satisfy all other program requirements will avoid the payment adjustment in CY 2017 if they successfully attest by October 1, 2016 and will avoid the payment adjustment in 2018 if they successfully attest by February 28, 2017 (with all other returning participants).

Visit the CMS website for more information on Meaningful Use payment adjustments and hardship exceptions.

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Value-Based Payment(VBP) Modifier Program

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. The VBP program uses Physician Quality Reporting System (PQRS) data to determine upward or downward payment adjustments based on quality and cost metrics annually.

The VBP is phased in based on practice size, and payment adjustments occur two years after the performance year (PQRS data collection year) on which they are based. CMS notifies eligible professionals (EPs) of their performance on quality and cost metrics and payment adjustment through Quality Resource and Use Reports (QRURs), which are issued in the year prior to the payment adjustment year. Groups with 10 or more EPs are subject to the 2016 Value Modifier based on their performance in 2014. CMS made the QRURs for performance year 2014 available on September 9, 2015. CMS established a 60-day Informal Review Period for EPs to request a correction of a perceived error in their 2016 Value Modifier calculation, which concludes on November 9, 2015.

All physicians will be subject to VBP payment adjustments in 2017 based on their performance on 2015 PQRS reporting. EPs that do not participate in PQRS will receive automatic downward payment adjustments in addition to the penalties for PQRS non-participation.

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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. The compliance deadline is October 1, 2015. Any guidance and information related to ICD-10 implementation will be posted here.

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ACP and Other Resources:

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Open Payments (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.

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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, acute 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:

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Chronic Care Management

In the 2015 Medicare Physician Fee Schedule, CMS indicated that they would begin reimbursing physicians for non-face-to-face chronic care management (CCM) services on January 1, 2015 using CPT® code 99490. This code covers, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; comprehensive care plan established, implemented, revised, or monitored.

This means that the code can be used on any Medicare patient with two or more chronic conditions (see above) with an allowed billing of 20 minutes of care management for every 30 days. The total RVU for billing 99490 to Medicare is 01.19 (which translates to an average payment of $42.60 from Medicare).

CMS also laid out a number of reporting and scope of service requirements associated with billing CCM. An office reporting CCM is required to develop a summary of care document for individual beneficiaries which must be able to be shared electronically (other than by fax) with all clinicians and clinical staff within practice who are furnishing CCM services. The document must be made available on a 24/7 basis. The clinician must also obtain the beneficiary's written consent before billing Medicare.

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ACP Chronic Care Management Toolkit (PDF)

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Advance Care Planning

The 2016 Medicare Physician Fee Schedule includes advance care planning codes that allow for reimbursement of end-of-life discussions.

The two new CPT codes describing advance care planning services are:

Implementation
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Advance Care Planning Toolkit (PDF)

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Quality Payment Program

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) ended the Sustainable Growth Rate formula and established the Quality Payment Program (QPP) which shifted Medicare Part B payments based on volume to to payment based on value. Physicians can choose how they want to participate in the QPP based on practice size, specialty, location, or patient population. The QPP has two tracks:

The performance period for QPP is a calendar year with payment adjustments occurring 2 years later. Performance data are submitted during the 1st quarter of the year following each performance period. The minimum score to remain neutral for 2019 participation (and subsequent payment adjustment in 2021) is 30 points. Small practices and practices in rural or underserved area will continue to receive bonus scoring advantages.

The Quality Payment Program (QPP) was established by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Under this program, eligible clinicians participate in one of two payment tracks to avoid penalties and earn potential increases in Medicare payments.

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Pick Your Pace

The first performance period for Quality Payment Program (QPP) is a transition period that runs from January 1, 2017, to December 31, 2017, with payment adjustments occurring in 2019. In this first year, CMS is offering flexible "Pick Your Pace" reporting options to MIPS participants, which ensure that eligible clinicians (ECs) and groups submitting even minimal data can avoid a payment adjustment, while those who are ready to do more robust reporting can be eligible for small positive payment adjustments and participation in advanced APMs. The Pick Your Pace reporting options for 2017 include:

All payment adjustments for 2017 performance will be applied in 2019. These maximum adjustments increase over the next few years, capping out at +/- 9 percent in performance year 2020.

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ACP's MACRA page

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Payment and Coding Updates

Below is list of codes that are available for use and payment. Check out ACP's Coding page for more information on Primary Care service codes.

Chronic Care Management and Complex Chronic Care Management

99490: Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month.

99487: Complex chronic care management services, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, chronic conditions place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline, establishment or substantial revision of a comprehensive care plan, moderate or high complexity medical decision making; 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month.

99489: Complex chronic care management services, each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month.

G2064: Comprehensive care management services for a single high-risk disease, e.g., Principal Care Management, at least 30 minutes of physician or other qualified health care professional time per calendar month with the following elements: Once complex chronic condition lasting at least 3 months.

G2065: Comprehensive care management for a single high-risk disease services, e.g. Principal Care Management, at least 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month with the following elements: one complex chronic condition lasting at least 3 months.

G2058: Chronic care management services, each additional 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month.

Care Planning

G0506: Comprehensive assessment of and care planning by the physician or other qualified health care professional for patients requiring chronic care management services, including assessment during the provision of a face-to-face service.

Psychiatric Collaborative Care Model

99492: Initial psychiatric collaborative care management, first 70 minutes in the first calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional.

99493: Subsequent psychiatric collaborative care management, first 60 minutes in a subsequent month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional.

99494: Initial or subsequent psychiatric collaborative care management, each additional 30 minutes in a calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional.

Behavioral Health Management

99484: Care management services for behavioral health conditions, at least 20 minutes of clinical staff time, directed by a physician or other qualified health care professional time, per calendar month.

Advance Care Planning

99497: Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate.

99498: Advance care planning; each additional 30 minutes.

Resources & Links

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ACP's Coding Resources page

ACP's New Primary Care Codes for Payment

Medicare Cards

Starting April 2018, CMS will begin mailing new Medicare beneficiary identification (MBI) cards to all beneficiaries. The new MBIs will have 11 digits including only numbers and uppercase letters. The new identifiers will be randomly generated and not based on Social Security Number (SSN).

The mailing schedule will be primarily based on geography, beginning with the Mid-Atlantic States, California, Oregon, Hawaii, Alaska, and the Pacific territories. (Learn more about the Mailing Schedule.) Also starting April 2018, Medicare patients can check the status of card mailings in their area on Medicare.gov.

During the transition period between April 2018 and December 2019, claims can include either the old Health Insurance Claim Number (HICN) or the new MBI. CMS will return both the HICN and the MBI on every remittance advice.

To see what the new cards will look like; go to the new Medicare card home page.

Practices are urged to remind patients to look out for their new card in the mail and to be sure and bring it to their next appointment.

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Appropriate Use Criteria

The AUC program, mandated by federal legislation, is an attempt to reduce unnecessary advanced diagnostic imaging, such as magnetic resonance imaging and computerized axial tomography scans. As part of the Medicare Physician Fee Schedule for 2018, the Centers for Medicare & Medicaid Services delayed implementing its Medicare Appropriate Use Criteria (AUC) Program for Advanced Diagnostic Imaging from 2018 to 2020. 2020 will be an "educational and operations testing year," in which physicians will be required to use AUC and report the information on their Medicare claims. However, CMS will pay radiologists' claims for advanced diagnostic images even if the ordering physician has not conducted the AUC consultation correctly.

Additionally, physicians who want to get experience in the AUC program in 2018 can participate on a voluntary basis beginning in July 2018 within the Quality Payment Program. Physicians can earn credit for an "improvement activity" under the Merit-Based Incentive Payment System (MIPS) by using a qualified clinical decision support (CDS) mechanism. This improvement activity was included in the 2018 QPP final rule.

The AUC program, mandated by federal legislation, is an attempt to reduce unnecessary advanced diagnostic imaging, such as magnetic resonance imaging and computerized axial tomography scans. As part of the Medicare Physician Fee Schedule for 2018, the Centers for Medicare & Medicaid Services delayed implementing its Medicare Appropriate Use Criteria (AUC) Program for Advanced Diagnostic Imaging from 2018 to 2020. 2020 will be an "educational and operations testing year," in which physicians will be required to use AUC and report the information on their Medicare claims, whereby claims will not be denied for failing to include proper AUC consultation information. . However, CMS will pay radiologists' claims for advanced diagnostic images even if the ordering physician has not conducted the AUC consultation correctly.

The program will be fully implemented on January 1, 2021.

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Interoperability, Info Blocking, and Patient Access

The 21st Century Cures Act required ONC to develop regulations to improve interoperability and patient access to electronic health information and deter information blocking. In May 2020, both ONC and CMS published final regulations that outline a number of requirements for physicians, health IT vendors, health information exchanges, and payers regarding enhancing electronic health information exchange and patient access to their data, including the use of modern health IT standards, standards-based APIs, and guidance regarding information blocking practices.

ONC 21st Century Cures Act: Interoperability, Information Blocking, and the ONC Health IT Certification Program: Final regulation aiming to improve patient access to data and electronic health information exchange, or interoperability. It is primary focused on the health IT vendor community, including health IT vendors and health information exchanges and networks, as well as the physicians using those systems. ONC updated elements of their certification program and outlined requirements for vendors to use standards-based application programming interfaces (APIs) to exchange health data electronically. Another significant portion of ONC's rule — and the aspect that is directly related to actions physicians take — includes ONC's definition of what constitutes information blocking, clarifying the 21st Century Cures Act definition, and outlines the eight exceptions to information blocking.

CMS Interoperability and Patient Access Final Regulation: Final regulation aiming to improve patient access to and electronic exchange of claims data. It is designed for payers who contract with the Agency (e.g., Medicare Advantage, Medicaid, CHIP, and Qualified Health Plan issuers on the Federally Facilitated Exchanges). CMS calls for payers to use the same standards-based APIs that ONC outlines for the vendor community in their rule. The goals of the CMS regulation are to improve patient access to data held by payers as well as exchange of electronic health information between payers.

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Coronavirus Disease 2019 (COVID-19)

There have been new Coronavirus Disease 2019 (COVID-19) practice management resources created:

Provider Relief Fund allocates payments to eligible providers to support those on the front lines and protect patients' access to care. These are payments, not loans, so recipients do not need to pay them back. However, there are reporting requirements and other restrictions explained in the resources provided.

The U.S. Small Business Administration (SBA) is currently not accepting new applications for COVID-19 relief loans or grants. They are offering Paycheck Protection Program (PPP) loan forgiveness.

The U.S. Equal Employment Opportunity Commission (EEOC) enforces workplace anti-discrimination laws, including the Americans with Disabilities Act (ADA) and the Rehabilitation Act (which include the requirement for reasonable accommodation and non-discrimination based on disability, and rules about employer medical examinations and inquiries), Title VII of the Civil Rights Act (which prohibits discrimination based on race, color, national origin, religion, and sex, including pregnancy), the Age Discrimination in Employment Act (which prohibits discrimination based on age, 40 or older), and the Genetic Information Nondiscrimination Act. Note: Other federal laws, as well as state or local laws, may provide employees with additional protections. They have also provided guidance (a publication entitled Pandemic Preparedness in the Workplace and the Americans With Disabilities Act [PDF Version]) ("Pandemic Preparedness"), consistent with these workplace protections and rules, that can help employers implement strategies to navigate the impact of COVID-19 in the workplace.

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