Those affected by the CMS decision include physicians treating patients with diabetes or chronic disease linked to cardiovascular and oncology diagnoses.


Jan. 27—Physicians will not face a penalty under the Physician Quality Reporting System (PQRS) if they are unable to meet 2016 requirements due to issues involving ICD-10 updates that were added to the code set on Oct. 1, 2016, federal officials announced.

The coding changes were associated with PQRS measures dealing with diabetes, pregnancy, and diagnoses related to cardiovascular, oncology, mental health, or eye disease issues, according to a Frequently Asked Questions page on the Centers for Medicare & Medicaid Services (CMS) website.

While it appears that only a handful of measure sets were affected, one coding expert noted that the diagnosis groups involved cover a lot of ground, meaning a significant percentage of physicians could have been penalized if CMS had not made the decision it did.

“Any doctor that has a lot of patients with chronic illnesses, it definitely would’ve affected them,” Nena Scott, director of coding quality and professional development at Tupelo, Miss.-based Trust Healthcare Consulting Services, said in an interview.

Although she hesitated to speculate how much money was involved, Scott said the financial implications would have been significant given that patients with multiple chronic diseases are “the ones who cost the most to treat.”

Physicians are frustrated by having to operate under an ever-changing set of rules, Scott said, so she thinks CMS did the right thing by not imposing penalties.

“Until they get everybody on the same page, I think it was important to do that,” Scott said.

Negative Adjustment

Penalties would have mostly taken the form of a negative adjustment to a physician’s or practice’s PQRS or Value Modifier payments for 2017 and 2018. Some physicians who were part of a Shared Savings Program accountable care organization (ACO) that failed to report on their behalf in 2015 will also be exempt, according to the ICD-10 section of the CMS PQRS website.

“CMS is acutely aware of the relationship between the ICD-10 update and quality reporting,” the agency stated on the website. It acknowledged that the coding updates will affect its own “ability to process data reported on certain quality measures.”

CMS “will always have issues with various things they can’t foresee,” Erin Solis, a regulatory compliance strategist with the American Academy of Family Physicians, said in an interview.

But she warned that physicians and practices who think they may be exempt should still file PQRS reports because CMS will still be making the final determination on whether they should be “held harmless” due to issues with the ICD-10 updates.

“If a physician doesn’t report at all, they could be subject to an automatic 2 percent negative payment adjustment,” Solis said. That cut will then affect future payments under the Merit-based Incentive Payment System track of the Medicare Access and CHIP Reauthorization Act (MACRA).

Administrative Burden

“There’s still some trepidation about the new program,” Solis said, referring to MACRA.

An intent behind MACRA was to provide relief for some of the administrative burden imposed by PQRS and other CMS quality programs. But Solis noted that the reporting burden “doesn’t look all that different” under the new law.

She also downplayed the likelihood of any effect on MACRA-related quality-reporting requirements from President Donald Trump’s pledge to ease burdens created by the Affordable Care Act (ACA).

“Repealing the ACA will not make MACRA go away,” Solis said.

Scott, however, believes the specificity enhanced by ICD-10 will eventually pay off by giving CMS more exact information on what it costs to treat patients and to better identify problem areas that require attention.

“It’s going to make a big difference when it comes to that point,” Scott said. To get to that goal physicians need to “be as specific as they can with diagnosis.”


Andis Robeznieks is a freelance writer based in Chicago. Follow Andis on Twitter at @AndisRobeznieks.

Publication Date: Friday, January 27, 2017