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MACRA

The CY 2018 MPFS & QPP Final Rules
What You Need to Know

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CMS recently published the CY 2018 Medicare Physician Fee Schedule (MPFS) and Quality Payment Program (QPP) Final Rules. Both rules include updates regarding the requirements for Appropriate Use Criteria (AUC) consultation when ordering Medicare Fee for Service Advanced Imaging exams and formally align the goals of PAMA and MACRA.

A Formal Alignment of PAMA and MACRA

The CY2018 MPFS Final Rule answered one fundamental question – “Is CMS serious about implementing Section 218b of PAMA?” – with a resounding “YES”. Furthermore, CMS clarified that the goals of the Quality Payment Program, also known as MACRA, are the result of separate yet associated statutory requirements. Rather than merge the programs, as many advocated, CMS exercised their statutory authority to formally align the programs.

The CY 2018 QPP Final Rule defined two Finalized Improvement Activities targeted at early adopters of the Medicare AUC program – AUC Consultation through a qCDSM and Cost Display for Laboratory and Radiographic Orders. This allow early adopters to receive MIPS points in both the Improvement Activities and Advancing Care Information Performance Categories.

  • AUC Consultation through a qCDSM is defined by CMS as a High-Weight Improvement Activity worth 20 points. In addition, AUC Consultation is also an eligible for a Advancing Care Information High-Weight Bonus.
  • Cost Display for Laboratory and Radiographic Orders is defined as a Medium-Weight Improvement Activity worth 10 points. In addition, Cost Display is also eligible for a Advancing Care Information Medium-Weight Bonus.

This alignment will create immediate financial impact through a Positive Payment Adjustment and set the stage for a compliant and accurate PAMA implementation.

NDSC’s CareSelect Platform enables organizations to align their imaging and enterprise CDS programs to target improvement activities in high priority MACRA measures. Targeted interventions in imaging, lab studies, blood management and other service lines can improve MIPS Quality Scores and build on the Advancing Care Information Bonus to maximize the positive payment adjustment.

Final Rule Fast Facts

• The CY 2018 Quality Payment Program (QPP) Final Rule defined that early adopters will receive a bonus on their Advancing Care Information MIPS Score if they attest to the consultation of a qualified Clinical Decision Support Mechanism during the 2018 MIPS reporting period.

• Claims for Medicare Part B Advanced Imaging Services will only be payable if they contain accurately formed evidence of the ordering provider’s consultation.

• CMS is implementing requirements for Ordering Providers to consult with Appropriate Use Criteria (AUC) as an alternative means to traditional forms of prior authorizations.

• The CY 2018 MPFS Final Rule defined in regulation that as of January 1, 2020 all claims for Part B advanced imaging services must contain evidence of AUC consultation.

Read Our Full CY 2018 Final Rule Write-Up

A Compliant Implementation

The PAMA program starts with a voluntary reporting period from July 2018—December 2019. Formal requirements for consultation and data submission will begin in January 2020 with a one-year “Educational and Testing” period. From January 2020, CMS will only pay claims if they include the necessary evidence of consultation. An ordering provider must consult AUC for every Medicare Part B advanced imaging order. Each claim will require evidence of consultation to be paid. During this educational period consultation information will not be used to determine outliers.

The timeline as outlined in the MPFS Final Rule allows organizations the required time to implement with a more thoughtful approach. The voluntary reporting period allows time for organizations to verify the accuracy of reported claims data to ensure payment in preparation for the January 2020 date and receive credit towards their MACRA score.

Questions on Claims & Reporting

In July’s MPFS proposed rule, CMS outlined an approach whereby G-Codes and HCPCS modifiers would be used to report consultation information on claims. This approach did not adequately connect the data generated at the encounter (consultation) with the data generated at the claim (furnished service).

Although CMS did not provide specific details regarding how claims will be formed. They did indicate that the Decision Support Number (DSN) generated by the mechanism will be the foundation for their approach. This information enables sites to plan order-entry and furnishing workflows that ensure the incorporation of consultation data.

In the recent Final Rule, CMS abandoned the G-Code approach in favor of a significantly less burdensome approach that will use Unique Decision Support Number (DSN). Utilizing a DSN simplifies the claims reporting process, allowing both sites and CMS to measure outcomes utilization and impact quality.

Learn More

We’ve updated our PAMA & MACRA page with all the details. We’ve also added extensive information about how we link to the provisions of MACRA. We’ll be updating all our regulatory resources on a regular basis as we get details from CMS

MACRA, a qCDSM and the Value-Based Payment Modifier

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CMS recently proposed that healthcare providers on the MIPS payment track who attest to consulting a qualified CDSM across all advanced imaging orders in 2018 will receive credit towards their practice improvement activity. When integrated with a CEHRT, they can receive an additional Advancing-Care information score.

During 2018, the “cost” category score will also contribute to future payment adjustments. The cost component of MACRA will be calculated based on the overall Medicare Spend-per-Beneficiary using the Value Based Payment Modifier. A better score translates to more payment.

When considering a PAMA compliance strategy, managing utilization across all Medicare services will become increasingly important.  A qCDSM with comprehensive AUC coverage and capabilities that impact utilization across all care settings, including pediatrics, becomes more important than ever.

CMS is telegraphing a stronger linkage between MACRA and the AUC provisions of PAMA. Further reinforcing the need for healthcare organizations to manage the overall utilization of services covered by Medicare using decision support tools in 2018.

Keep Reading:

From the NDSC Blog:
The CY2018 Medicare Physician Fee Schedule (MPFS) Proposed Rule – The Upshot
PAMA and MACRA – A Surprising Twist

From the Quality Payment Program:
QPP Proposed Rule Summary
Quality Payment Program Homepage

PAMA and MACRA – A Surprising Twist

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In the recent proposed rule for year two of The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the Centers for Medicare and Medicaid Services (CMS) have introduced a surprising twist – linking the Protecting Access to Medicare Act (PAMA) to MACRA.

Tucked away on page 178 of the proposed rule is a new improvement activity linked to the Advancing Care Performance Category. This improvement activity allows organizations who have implemented a qualified Clinical Decision Support Mechanism (qCDSM) to receive credit in this category:

A MIPS eligible clinician would attest that they are consulting specified applicable appropriate use criteria (AUC) through a qualified clinical decision support mechanism for all advanced diagnostic imaging services ordered. This activity is for clinicians that are early adopters of the Medicare AUC program (e.g., 2018 performance year) and for clinicians that begin the program in future years as will be required by CFR §414.94 (authorized by the Protecting Access to Medicare Act of 2014). Qualified mechanisms will be able to provide a report to the ordering clinician that can be used to assess patterns of image-ordering and improve upon those patterns to ensure that patients are receiving the most appropriate imaging for their individual condition.

This development provides some tantalizing useful and important insight into the PAMA regulatory process:

  1. Providers must attest to consulting the qCDSM across all advanced imaging. We recognize that CMS has yet to publish the anticipated 3rd MPFS proposed rule; however this should clear up any mystery about limiting consultations to just the 8 Priority Clinical Areas (PCA). NDSC’s interpretation has always been that all advanced imaging orders require a consultation of applicable AUC, not just the PCAs.
  2. Our interpretation is that the timing for PAMA will now align with the first MACRA payment adjustment. CMS is rewarding providers who have or are currently adopting AUC based on CMS’ guidance that starting Jan 1 2018, claims for Medicare Part B advanced imaging services require evidence of a qCDSM consultation.

In short, the country’s largest payer now requires consultation with a qCDSM across all advanced imaging services. This is certain to have implications for traditional utilization management approaches that rely on prior authorization through third parties.

Useful Links: MACRA Proposed Rule Fact Sheet