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Physician & Practice Timeline

Previous Quarters

Following is an archive of important dates related to a variety of regulatory, payment, educational, and delivery system changes and requirements.

Note: The items listed on this page are archived. To return to the current events use the button below.

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: Ongoing Items

Check the items below for guidance on what you should be working on, collecting, and thinking about right now.

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.

Resources & Links

ACP Resources:

Trusted External Resources:

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.

Resources & Links

ACP Resources:

Trusted External Resources:

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:

Resources & Links

ACP Resources:

  • PQRS Tools
  • PQRSwizard: a fast, convenient, and cost-effective online tool to help collect and report quality measure data for the Centers for Medicare & Medicaid Services (CMS) PQRS incentive payment program.

Trusted External Resources:

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 have successfully demonstrated meaningful use by October 1, 2014.

Visit the CMS website for more information on Meaningful Use payment adjustments and hardship exceptions. CMS has posted the streamlined MU hardship exception applications as well as guidance for eligible professionals on how to apply. The deadline for applying for a hardship exception for the 2015 MU reporting period and 2017 payment adjustments is July 1, 2016.

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.

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.

Resources & Links

ACP Resources:

ACP and Other Resources:

Trusted External Resources:

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.

Resources & Links

ACP Resources:

Trusted External Resources:

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:

  • 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. Schedule the face-to-face visit. Billing should occur on the date of the face-to-face visit. As of 1/1/2016, you no longer need to wait until the end of the 30-day post discharge period.
  • Day 3-30: Provide non-face-to-face care management (refer to list of physician/clinical staff activities).
Resources & Links

ACP Resources:

Trusted External Resources:

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 beneficiarys written consent before billing Medicare.

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:

  • 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 professional; first 30 minutes, face-to-face with the patient, family member(s) and/or surrogate.
  • 99498 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 professional; each additional 30 minutes. (List separately in addition to code for primary procedure.)
Implementation
  • Advance Care Planning can occur at any time. It can be done at the same time as the Annual Wellness Visit (AWV) or as part of an E&M, Transition Care Management (TCM), or Chronic Care Management (CCM) visit. (See below for how to bill Advance Care Planning.)
  • Some patients may have existing documents, such as a living will, advanced directive, or medical power of attorney. Over time, as the patient ages and conditions change, these documents may all need to evolve to accommodate these changing circumstances.
  • Use a standard format to guide the discussion. Each state has a standard form, but there are also others available through hospice and aging organizations. Sample forms can be found using the Resources section below.
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