Are You Ready for MACRA and MIPS: The New Healthcare Payment Reform
CDI professionals in the outpatient setting will increase as a result of MACRA legislation
Question: The Medicare Access and CHIP Reauthorization Act (MACRA) regulations and legislation will take effect in 2019. Financial opportunities for high performance providers will be based on quality, value, and accountability. How will this affect documentation and coding? How can we improve?
Answer: First, let’s explore the basics about MACRA and the Merit-Based Incentive Payment System (MIPS) and then discuss how clinical documentation improvement (CDI) is more important than ever.
What Is MACRA?
MACRA legislation was signed into law by President Obama in 2015. It is the new system that will replace all existing quality reporting systems. The Centers for Medicare & Medicaid Services’s (CMS’s) goal is to increase the focus on value-based care and quality. MACRA replaces the sustained growth rate (SGR) formula that was used to calculate payment cuts for physicians. Now, physicians and practitioners will be rewarded for providing higher quality care through two different payment options or tracks—MIPS and alternative payment models (APMs). Physicians and practitioners will need to participate in either the MIPS or an APM; however, most providers will be subject to MIPS.
What Is MIPS?
MIPS is a new program that will determine Medicare payment bonuses and penalties based on performance. Eligible professionals (more commonly referred to as EPs) may receive a bonus, penalty, or no payment adjustment at all. EPs are those providers who have 100 or more Medicare Part B patients or more than $30,000 in Medicare allowables. MIPS does not apply to hospitals.
MACRA legislation combines the three existing items below into MIPS—a single incentive program.
- The existing Physician Quality Reporting System (PQRS)
- Value-Based Payment Modifier (VMA)
- Medicare Electronic Health Record (EHR) incentive program known as meaningful use
A physician or practitioner’s performance score will now be based on four performance categories: quality, resource use, clinical practice improvement activities, and meaningful use. Payments to providers will continue to be based on the Medicare Part B fee schedule; however, payments can be adjusted positively or negatively depending upon the final scores of these four performance categories.
What are APMs?
APMs are the alternative to MIPS. Providers who participate in APMs can opt out of MIPS. While APMs do provide financial incentives similar to MIPS, there is an increased burden of revenue risk and quality measurement. APMs move further away from the traditional fee-for-service payment model to models that tie payments to value and focus on better care, smarter spending, and a healthier patient population. APMs include accountable care organizations (ACOs), patient centered medical homes (PCMHs), and bundled payment models.
CDI Is More Important Than Ever
Most inpatient physicians and healthcare practitioners are familiar with the CDI staff in their hospitals, but CDI professionals in the outpatient setting will increase as a result of MACRA legislation. One key area that will continue to be a focus is documentation and coding related to hierarchical condition categories (HCCs). HCCs capture the severity of illness as well as acute and chronic conditions for patients. The risk scores associated with HCCs are tied to payment and are based on documented diagnoses. Therefore, the need for specific and complete documentation is a must. If you have not implemented any formal training or education in your practice, now is the time to consider its importance.
For more information on MACRA, visit the following CMS websites:
Quality Payment Program, https://qpp.cms.gov/
CMS’s MACRA homepage, https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html
The Medicare Access & CHIP Authorization Act of 2015, Path to Value, https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-LAN-PPT.pdf
Jeanie Heck, BBA, CCS, CPC, CRC, is director of education, Intellis.
Kim Felix, RHIA, CCS, is vice president of education and training, Intellis.