Compliance Programs in Healthcare: Understanding Roles and Benefits, Study notes of Medicine

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AAPC CPC PREP COURSE - CHAP 1 NOTES

AAPC CPC PREP COURSE

(HAGERSTOWN COMMUNITY COLLEGE)

CPC Course - Chap 1 Notes

The Business of Medicine

Coding as a Profession ● Medical Coding - process of translating a healthcare provider’s documentation of a patient encounter into a series of numeric or alphanumeric codes ○ Separate code sets to describe diagnoses, medical and surgical services/procedures, and supplies ○ Universal shorthand language to: ■ Ease data collection ■ Evaluate quality of care ■ Determine costs and reimbursement ● Coding Systems - used in ambulatory settings, provider offices, long-term care ○ CPT, HCPCS Level II, ICD-10-CM ○ Coding ties directly to reimbursement - codes must be assigned correctly to ensure proper payment ● Code assignment - determined by provider’s documentation and unique rules that govern each code set ○ Vary depending on who is paying for patient’s care ● Medical Care is complex and variable - as are coding requirements ○ Precise coding -requires a thorough understanding of coding guidelines, mastery of anatomy and medical terminology ○ Must be detailed oriented ● If a provider’s documentation is inaccurate or incomplete - will not translate properly to the language of coeds → will not get properly reimbursement ○ Must: ■ Evaluate the documentation for completeness and accuracy ■ Communicate regularly with the physician to ensure documentation requirements set by payers are met ○ May use computer programs to tabulate and analyze data to improve: ■ Patient care ■ Better control costs ■ Provide documentation for use in legal actions, or use in research studies ● Coders who specialize in inpatient coding are referred to as health information coders, medical record coders, coder/abstractors, or coding specialists ○ Assign a code to each diagnosis and procedure documented ■ Rely on their knowledge of disease processes ○ Coders then use classification system software to assign the patient to one of the several hundred Medicare Severity-Diagnosis Related Groups (MS-DRG) ■ MS-DRG determine the amount of hospital will be reimbursed if the patient is covered by Medicare or other insurance programs using the MS-DRG system ● Coders can also specialize in Cancer registry ○ Cancer registrars maintain facility, regional, and national databases of cancer patients ○ Review patient records and pathology reports to assign codes for the diagnosis and treatment of different cancers and select benign tumors ○ Conduct annual follow-ups on all patients in the registry to track treatment, recovery, and survival

○ Calculate survival rates of various treatments, locate geographic areas with high incidences of certain cancers, and identify potential participants for clinical drug trials ● Continuing Education - very essential for coders ○ Codes and policies can change quarterly ● Adoption of EHR - broaden and alter coders’ responsibilities ○ Must be familiar with EHR software ○ Maintaining security ○ Analyzing electronic data to improve healthcare information ○ Assist in improving EHR software and contribute to the development and maintenance of health information networks ○ Take on auditing role in reviewing EHR code suggestions based on documentation ● Coding is a technical and rapidly changing field ○ Skilled coders may become - consultants, educators, medical auditors ○ Evolved over the past several decades and will continue to do so ■ As healthcare embraces new technologies, code sets and payment methodologies The Difference Between Hospital and Provider Services ● Outpatient coding - pertains to provider services ○ Outpatient coders use CPT, HCPCS Level II and ICD-10-CM ○ Work in provider offices, outpatient clinics, facility outpatient departments ○ Outpatient facility coders also use Ambulatory Payment Classifications (APCs) ○ Have more interaction with providers throughout the day ● Inpatient coding ○ Use ICD-10-CM and ICD-10-PCS codes ○ Also use MS-DRGs for reimbursement ○ Less direct interaction with providers How Provider Office Works and How the coder Fits ● Patient visits the medical practice → front desk person obtains insurance and demographics (or information is electronically obtains before visit) → info is entered into practice management system → provider sees the patient → provider documents visit in patient medical record and completes encounter form → at completion of visit, patient checks out and pays copay if applicable ● After patient leaves office → documentation is translated into procedure or supply codes (CPT or HCPCS) and diagnosis codes (ICD-10-CM) → this information is submitted on a claim to the insurance company or payer to obtain reimbursement ○ This translation of documented information from the visit is referred to as coding ○ Coding - can be reformed by provider, EHR, or Coder ■ When the provider or EHR performs the coding, the coder takes over the role of auditor to verify the documentation supports the codes selected ■ When the coder performs the coding, the coder reviews the provider’s documentation and codes the services based on what is documented in the patients records ● After the documentation is translated to codes → they are assigned a fee and billed to the patient or payer ○ The place of service code is reported to indicate where services were performed ■ These are found in the CPT code book ○ The charges are billed to payer using the CMS-1500 claim form (available in both paper & digital formats) ■ Many payers now only accept electronic claims ● These benefit the medical office by allowing timely submissions to the payer and proof of transmission of the claim ■ Payers uses the codes to identify the services performed and to determine payment or denial ● The determination is sent to the provider in the form of a remittance advice (RA) or explanation of benefits (EOB) ○ These explain the payer’s determination in payment

○ If a service is denied → responsibility to validate or appeal the denial often falls on the coder Understanding the Hierarchy of Providers ● Medical offices and hospitals have a variety of medical providers (requires different levels of education) ○ Scope of Practice - refers to the States individual proactive guidelines for each level of a provider ○ Physician - 4y college, 4y medical school, 3-5y or more of residency (medical training medical specialty) ■ Can also continue training in a subspecialty - called a fellowship ○ Mid-level Providers - work in the same office as Physician - also know as physician extenders (extend work of the physician) ■ Physician Assistants ● Licensed to practice medicine with physician supervision ● PA program ~26.5 months to complete after bachelor’s degree ■ Nurse Practitioners ● Master’s degree in Nursing ■ Mid-level providers - generally reimbursed at a lower rate than physicians ● Scope of practice varies by state but mid-level providers typically require oversight by physician The Different Types of Payers ● Some patients pay medical expenses out-of-pocket, but mort patients are covered under at least one health plan ○ Significant as individual payers may specify coding requirements in addition or even contradictory to CPT guidelines and those created by CMS ● 2 types of payers -finer distinctions within these categories ○ Private - commercial carriers ■ Have both group and individual plans ■ Contracts provided vary, but usually include hospitalization, basic, major medical coverage ○ Government ■ Medicare - primary government payer in US ● Federal health insurance, administered by CMS, provides coverage for people 65 and older, blind, disabled, people with permanent kidney failure or end-stage renal disease ● CMS regulations often influence coding requirements for Medicare and non-Medicare payers alike ● Made up of several parts: ○ Medicare Part A - helps cover inpatient hospital care & skilled nursing facilities, hospice, and home health ○ Medicare Part B - covers 2 types of services: ■ Medically necessary provider services - need to diagnose or treat a medical condition and that meet accepted standards of medical proactive ■ Preventive services - prevent illness, detect illness at an early stage ■ Medicare Part B is an optional benefit for which the patient pays a monthly premium, annual deductible, 20% co- insurance, except for preventive services covered under healthcare law ○ Medicare Part C - Also Called Medicare Advantage ■ Combines benefits of Part A & B and sometimes Part D ■ Plans are managed by private insurers approved by Medicare and may include PPOs, HMOs or others ■ Plans may charge different copays, coinsurance or deductibles for services

■ THe CMS Hierarchical condition category (CMS-HCC) risk adjustment model provides adjusted payments based on a patient’s diagnosis and co-morbidities ● There may be loss of additional reimbursement to which the provider is entitled ○ Medicare Part D - prescription drug program available to all Medicare beneficiaries for a fee ■ Private companies approved by Medicare provide the coverage ■ Medicaid - health insurance assistance program sponsored by federal and state governments for low-income people (including children and pregnant women) ● Administered on a state-by state bases → coverage varies ○ Though each state adheres to certain federal guidelines ● State-funded insurance programs that provide coverage for children up to 21 include: Children’s Medical Services, Children’s Indigent Disability Services, Children with Special Healthcare Needs ● program s are designed for beneficiaries with specific chronic medical conditions ● Each provider must decide whether to contract with private insurance carriers or government programs ○ When contracted with the insurance carrier→ provider is considered a “participating provider” (par provider) ■ Required to accept the allowed payment amount determined by the insurance carrier as fee for payment and follow all other guidelines in contract ■ The difference between the provider’s fee insurance carrier’s allowed amount is adjusted by the participating provider ○ Non-participating provider (not contracted) is not required to make adjustment ■ For Medicare services, even is a provider is non-participating - set limits on what the patient can be charged - referred to as a limiting charge The Medical Record ● Medical record - provider’s documentation of pertinent facts and observations about a patient’s health history, including: ○ Past & present illnesses ○ Tests ○ Treatments ○ Outcomes ● Chronologically documents patient care to assists in the continuity of care between providers facilitate claims review and payment & serve as a legal document ○ All services provided to a patient are documented in the medical record ○ Administrative data (ex: financial records) should not be included in the medical record or provided in response to a subpoena or request for medical records ● EHRs are slowly replacing paper records ○ This relatively new technology creates opportunity for both improved efficiency and heightened compliance risks Evaluation and Management Documentation ● E/M services are often provided in a standard format such as SOAP notes: ○ S - Subjective - the patient’s statement about his or her health, including symptoms ○ O - Objective - the provider’s examination and documentation of the patient’s illness using observation, palpation, auscultation, and percussion ■ Tests and other services performed may be documented here as well ○ A - Assessment - Evaluation and conclusion made by the provider

■ This is usually where you find the diagnosis(es) that supports the services rendered ○ P - Plan - Course of action. Here the provider will list the next steps for the patient, whether it’s ordering additional tests, taking over-the-counter medications, etc ● Not all E/M documentation is written in a clear SOAP format, but each chart must contain the required components of the visit associated with the code(s) billed Operative Report Documentation ● Operative reports are used to document the detail of a procedure performed on a patient ○ Most operative notes have a header and a body in the report ■ The header should include: ● Date and time of the procedure ● Names of the surgeon, co-surgeon, assistant surgeon ● Type of anesthesia and anesthesia provider name ● Preoperative and postoperative diagnosis ● Procedure performed ● Complications ■ The body should include: ● Indication for surgery ● Details of the procedure(s) ● Findings ○ Approximately 20% of an operative report contains words that are less important to a coder as they are not needed to report the services or procedures ■ A coder is tasked with breaking down the info and applying correct codes ● Operative Report Coding Tips! ○ Highlight unfamiliar words - research for understanding ○ Diagnosis code reporting - use the postoperative diagnosis for coding unless there are further defined diagnoses or additional diagnoses found in the body of the operative report. ■ If a pathology report is available, use the findings from the pathology report for the diagnosis ○ Start with the procedures listed - one way of quickly starting the research process is by focusing on the procedures listed in the header. ■ Read the note in its entirety to verify the procedures performed ■ Although procedures listed in the header may not be listed correctly and procedures documented within the body of the report may not be listed in the header at all, it is a place to start ○ Look for keywords - keywords may include locations and anatomical structures involved, surgical approach, procedure method (debridement, drainage, incision, repair, etc), procedure type (open, closed, simple, intermediate, etc), size and number, and the surgical instruments used during the procedure ○ Ready the body - all procedures reported should be documented within the body of the report ■ The body may indicate a procedure was abandoned or complicated possibly indicating the need for a different procedure code or reporting of a modifier Medical Necessity ● Medical Necessity - related to whether a procedure or service is considered appropriate in each circumstance ○ An Extreme example: partial amputation of a limb may be medically necessary to eradicate a tumor or severe reaction ■ But definitely not medical necessary to treat a splinter ● Generally a medically necessary service or procedure is the least radical service/procedure that allows for effective treatment of the patient’s complaint or condition ● CMS has developed policies regarding medical necessity based on regulations found in title XVIII of Social Security Act

○ Describes whether specific medical items, services, treatment procedures, or technologies can be paid for under Medicare ○ Services and procedures are covered only when linked to a designated, approved diagnosis ○ Non-covered items are deemed not reasonable and necessary ● Medicare (and many insurance plans) may deny payment for a service that is not reasonable and necessary, according to the Medicare reimbursement rules ○ When a provider treats a Medicare beneficiary, they should bill only those services that meet the Medicare standard of reasonable and necessary for the diagnosis and treatment of a patient ● National Coverage Determinations (NCD) explain when Medicare will pay for items or services ● Each Medicare Administrative Contractor (MAC) is responsible for interpreting national policies into regional policies ○ These are called Local Coverage Determinations (LCD) ■ LCDs further define when an item or service will be covered ■ Have jurisdiction only within their region ○ MACs may also define what codes are needed for coverage in a related billing and coding article ● If an NCD doesn’t exist for an item, it is up to the MAC to determine coverage ○ According to CMS guidelines “Where coverage of an item or service is provided for specified indications or circumstances but is not explicitly excluded for others, or where the item or service is not mentioned at all in the CMS Manual System, the Medicare contractor is to make the coverage decision, in consultation with its medical staff, and with CMS when Appropriate, based on the law, regulations, rulings, and general program instructions” ● Practices should check policies quarterly to maintain compliance ● The LCD explains when the service is indicated or necessary and identifies limitations on coverage ● There may also be documentation guidelines associated with the LCD ○ This section should be checked to determine if additional information is required to be sent on or with the claim form for the service to be covered, or if specific results are required in the documentation ○ This sections also identifies if there is an associated billing and coding article ● LCDs also provide a revision history to identify when and what changes were made to the LCD ● The 2016 21st Century Cures Act made changes to the LCD process and requires each MAC that develops an LCD to make the following information available on its website and the medicare website 45 days before the effective date: ○ The determination in its entirety ○ Where and when the proposed determination was first made public ○ Hyperlinks to the proposed determination and a response to comments submitted to the contractor with respect to such proposed determination ○ The summary of evidence that was considered by the contractor during the development of such determination and a list of the sources of such evidence ○ An explanation of the rationale that supports such determination ● The Act also requires MACs to remove all codes from LCDs and place them in billing and coding articles that are linked to the LCD ○ These articles can be found on the MACs website or on the Medicare Coverage Database ○ The articles contain the coverage guidance, specific CPT and ICD-10-CM codes, Bill Type codes, and Revenue codes, in addition to codes that are specifically noted as not supported by medical necessity ● If you are providing a service and the Medicare patient’s diagnosis doesn’t support the medical necessity requirements per the LCD and billing and coding article, the service may not be covered ○ In such a case, the practice would be responsible for obtaining an Advance Beneficiary Notice of Noncoverage (Advance Beneficiary Notice or ABN) ● Commercial (non-Medicare) payers may develop their own medical policies, which do not necessarily follow Medicare guidelines

○ They may be specified in private contracts between the payer and the practice or providet or referenced in provider manuals found on the payer’s website ○ Coders need to be aware of the contract requirements of the individual commercial payers wto which they submit claims The Advance Beneficiary Notice ● Medicare beneficiaries and providers have certain rights and protections related to financial liability ○ These financial liability and appeal rights and protections are communicated to beneficiaries through notices given by providers ● Providers should use an Advance Beneficiary Notice (ABN) when a Medicare beneficiary requests or agrees to receive a procedure or service that Medicare may not cover ○ The ABN is a standardized form that explains to the patient why Medicare may deny the service or procedure ○ ABN protects the provider’s financial interest by creating a paper trail that CMS requires before a provider can bill the patient for payment if Medicare denies coverage for the service or procedure ● Providers must complete the one-page form in full, giving the patient an explanation as to why Medicare is likely to refuse coverage for the proposed procedure or service ○ Common reasons Medicare may deny a procedure or service include: ■ Medicare doesn’t pay for the procedure/service for the patient’s condition ■ Medicare doesn’t pay for the procedure/service as frequently as proposed ■ Medicare doesn’t pay for experimental procedures/services ● The standards for use of the ABN are listed in Section 50 of the Medicare Claims Processing Manual ○ This quick guide is an abbreviated reference tool and is not meant to replace or supersede any of the directives contained in Section 50 ● The explanation of why Medicare may deny the service or procedure should be as specific as possible ○ A simple statement that Medicare may not cover this procedure is not sufficient, and ABNs may not be given to all Medicare patients routinely ● The provider must present the patient with a cost estimate for the proposed procedure or service ○ CMS instructions stipulate, “Notifiers must make a good faith effort to insert a reasonable estimate… the estimate should be within $100 or 25% of the actual costs, whichever is greater” ○ Medicare allows an estimate that substantially exceeds the actual costs as the beneficiary “would not be harmed if the actual costs were less than predicted” ● CMS rules require the provider to present the ABN “far enough in advance that the beneficiary or representative has time to consider the options and make an informed choice” ○ The ABN “must be verbally reviewed with the beneficiary or his or her representative and any questions raised during that review must be answered” before the patient signs the ABN ● When ABN is completed and reviewed in full, the Medicare beneficiary may choose to proceed with the procedure/service and assume financial responsibility or may elect to forego the procedure or service ○ If patient chooses to proceed, he or she may request the charge be submitted to Medicare for consideration (with understanding that it will probably be denied) ○ A copy of the completed, signed form must be given to the beneficiary or representative, and the provider must retain the original notice on file ● The patient’s signature is not required for assigned claims (that is, claims submitted by and paid to a healthcare provider on behalf of the beneficiary) ○ If the beneficiary refuses to sign a properly presented ABN, but still requests the procedure or service, the provider should document the patient’s refusal ○ The provider and a witness should then sign the form ● In the case of unassigned claims (when claims are submitted by the provider but the payment is sent to the patient who then reimburses the healthcare provider), a signature is required on the ABN to hold the patient financially liable

○ If the patient refuses to sign, the only options are not to provide the service or procedure (which might raise potential negligence issues) or to provide the service with the understanding that the provider may not be able to recoup payment from either Medicare or the beneficiary ● An ABN should not be used to bill the beneficiary for additional fees beyond what Medicare reimburses for a given procedure or service ○ ABN doesn’t allow the provider to shift liability to the beneficiary when Medicare payment for a particular procedure or service is bundled into payment for other covered procedures or services ● Providers should list on the ABN every recommended procedure or service that might not be covered ○ Although liability for non-covered services normally rests with the beneficiary, Medicare relieves beneficiaries from financial liability where they did not know and did not have reason to know a service would not be covered ○ Without a valid ABN, the Medicare beneficiary cannot be held responsible for denied charges ● NOTE: ABNs are never required in emergency or urgent care situations ○ CMS policy prohibits giving an ABN to a patient who is under duress, including patients who need Emergency services before stabilization ○ When screening and stabilizing care is denied by Medicare as medically unnecessary, healthcare providers cannot seek payment from beneficiaries ● Non-Medicare payers may not recognize the ABN ○ Careful Research is needed to determine validity of an ABN outside of Medicare ○ In some instances, payer contracts may have a “hold harmless” clause within the language that prohibits billing the patient for anything other than co-pays or deductibles The Health Insurance Portability and Accountability Act of 1996 (HIPAA) ● The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a 5-part Act ○ AKA: Kennedy-Kassebaum Law, Kennedy Kassebaum Act ● Title II - Preventing Healthcare Fraud and Abuse, Administration Simplification, and Medical Liability Reform is the most important title concerning the position of a medical coder ● Title II - Administrative Simplification speaks to the increasing use of technology in the healthcare industry and addresses the need for: ○ National standards for electronic healthcare transactions and code sets ○ National unique for providers, health plans, and employers ○ Privacy and security of health data ● Under federal guidelines, HIPAA defines a covered enitity as any of the following: ○ A healthcare provider, such as: ■ Doctors ■ Clinics ■ Psychologists ■ Dentists ■ Chiropractors ■ Nursing homes ■ Pharmacies ○ A health plan, to include: ■ Health insurance companies ■ HMOs ■ Company health plans ■ Government programs that pay for healthcare, such as Medicare, Medicaid, the military and veterans’ healthcare programs ● The definition of health plan in the HIPAA regulations excludes any policy, plan, or program that provides or pays for the cost of expected benefits. Excepted benefits include: ○ Coverage only for accident or disability income insurance, or any combination thereof ○ Coverage issued as a supplement to liability insurance

○ Liability insurance, including general liability insurance and automobile liability insurance ○ Workers’ compensation or similar insurance ○ Automobile medical payment insurance ○ Credit-only insurance ○ Coverage for on-site medical clinics ○ Other similar insurance coverage, specified in regulations, under which benefits for medical care are secondary or incidental to other insurance benefits ○ A healthcare clearinghouse: this includes entities that process nonstandard health information they receive from another entity into a standard format (such as a standard electronic format or data content) or vice versa ● The legislation also required the establishment of a national Healthcare Fraud and Abuse Control Program (HCFAC), under the joint direction of the attorney general and the secretary of HHS, acting through the department’s inspector general ○ The HCFAC program is designed to coordinate, federal, state, and local law enforcement activities with respect to healthcare fraud and abuse The Need for National Standards for Electronic Healthcare Transactions and Code Sets ● CMS states “transactions are electronic exchanges involving the transfer of information between two parties for a specific purpose” ○ National standards for electronic healthcare transactions are designed to improve efficiency and effectiveness of the healthcare system by standardizing the formats used for electronic transactions ○ The transactions include: ■ Health claims and equivalent encounter information ■ Enrollment and disenrollment in a health plan ■ Eligibility for a health plan ■ Healthcare payment and remittance advice ■ Health plan premium payments ■ Health claim status ■ Referral certification and authorization ■ Coordination of benefits ● Any covered entity performing one of these transactions electronically is required to follow the standards set for standard use ○ The code sets include: ■ HCPCS (Healthcare Common Procedure Coding System) ■ CPT (Current Procedural Terminology) ■ CDT (Common Dental Terminology) ■ ICD-10-CM (Prior to October 1, 2015, this was ICD-9-CM) ■ NDC (National Drug Codes) ● An additional standard required in all transactions is unique identifiers for providers, health plans, and employers ○ The identifier for providers is the National Provider Identifier (NPI) ○ The identifier for employers is the Employer Identification Number (EIN) ■ Issued to employers by the IRS The Need for Privacy and Security ● HIPAA provides federal protections for protected health information (PHI) when held by covered entities ○ If an entity is not a covered entity, it doesn’t have to comply with the Privacy Rule or the Security Rule ● The Office for Civil Rights (OCR) enforces the HIPAA Privacy Rule, which protects the privacy of individually identifiable information; ○ The HIPAA Security Rule sets national standards for the security of electronic protected health information

○ The Confidentiality provision of the Patient Safety Rule, which protect identifiable information being used to analyze patient safety events and improve patient safety ● The OCR related a documenta called HIPAA Administrative Simplification ○ Discusses the healthcare provider’s responsibility surrounding PHI for treatment, payment, and healthcare operations (TPO) ○ Healthcare providers are responsible for developing Notices of Privacy Practices and policies and procedures regarding privacy in their practices How HIPAA Works ● A key provision of HIPAA is the minimum necessary requirement ○ Only the minimum necessary PHI should be shared to satisfy a particular purpose ○ If information is not required to satisfy a particular purpose, it must be withheld ● Under the Privacy Rule, the minimum necessary standard doesn’t apply to the following: ○ Disclosures to or requests by a healthcare provider for treatment purposes ○ Disclosures to the individual who is the subject of the information ○ Uses or disclosures made pursuant to an individual’s authorization ○ Uses or disclosures required for compliance with the HIPAA Administrative Simplification Rules ○ Disclosures to the US Department of Health & Human Services (HHS) when disclosures of information is required under the Privacy Rule for enforcement purposes ○ Uses or disclosures required by other law ● It is the responsibility of a covered entity to develop and implement policies bes suited to its circumstances to meet HIPAA requirements ○ As a policy requirement, only those individuals whose job requires it may have access to PHI ○ Only the minimum PHI required to do the job should be shared ○ If the entire medical record is necessary, the covered entity’s policies and procedures must state so explicitly and include justification HITECH and its Impact on HIPAA ● The Health Information Technology for Economic and Clinical Health Act (HITECH) was enacted as part of the American Recovery and Reinvestment Act of 2009 (ARRA) “to promote the adoption and meaningful use of health information technology ○ Portions of HITECH strengthen HIPAA rules by addressing privacy and security concerns associated with the electronic transmission of health information ○ HITECH established four categories of violations - depending on the covered entity’s level of culpability for releasing protected information - and minimum and maximum penalties. ○ HITECH also lowers the bar for what constitutes a violation but provides a 30-day window during which any violation not due to willful neglect may be corrected without penalty ○ HITECH allows patients to request an audit trail showing all disclosures of their health information made through an electronic record ○ HITECH also requires an individual to be notified if there is an unauthorized disclosure or use of his or her health information ● As the use of electronic medical records and transactions become more widespread, so too will concern over the protection and privacy of medical records ○ All individuals working within healthcare have a role in safeguarding patients’ private medical information The Quality Payment Program ● In 2015, Congress passed the Medicare Access and CHIP Reauthorization Act (MACRA), which provided significant changes to the healthcare delivery system ○ MACRA repealed the sustainable growth rate (SGR) formula used to calculate Medicare Part B payment updates to participating physicians ■ This move prevented a lofty reduction to physician payments in 2015 and provided 0. percent rate increases to the Medicare Part B singled conversion factor through 2019 ○ MACRA also laid the groundwork for a new quality incentive payment program called the Quality Payment Program (QPP)

■ QPP launched in 2017 ● Provides 2 tracks in which eligible clinicians can participate ○ Merit-Based Incentive Payment System (MIPS) ○ Advanced Alternative Payment Models (APMs) Merit-Based Incentive Payment System (MIPS) ● MIPS - combination of three former quality initiative programs ○ Physician Quality Reporting System (PQRS) ○ Medicare Electronic Health Record Incentive Program or Meaningful use ○ Value-Based Payment Modifier (VM) ○ One new component ● The goal of MIPS is to provide a single quality reporting system with a single payment adjustment factor based on individual or group performance in Medicare Part B ○ MIPS is a budget neutral program, meaning successful reporters of measure data earn positive payment adjustment funded by unsuccessful reporters who receive negative payment adjustments ● Per MACRA, minimum/maximum payment adjustments increase each year during the transition period: ○ MIPS eligible clinicians/groups’ Medicare Part B payment adjustments are based on performance thresholds in measures and activities ○ The performance threshold and payment adjustment statutorily increase each year until the maximums are reached in performance year 2021 (payment year 2023) ● Actual payment adjustments depend on individual/group performance and the ratio of successful reporters to unsuccessful reporters in a performance period ○ EX: a MIPS eligible clinician with a final score between 50 to 100 points in 2021 could potentially receive a positive 0-9% payment adjustment in 2023 MIPS Eligible Clinicians ● Not all Medicare part B-enrolled providers are eligible to participate in MIPS ○ The Definition of a “MIPS eligible clinician” is up to the discretion of CMS and subject to change ○ MIPS eligible clinicians include: ■ Physicians ● Doctors of chiropractic ● Doctors of dental medicine ● Doctors of dental surgery ● Doctors of medicine ● Doctors of optometry ● Doctors of osteopathy ● Doctors of podiatric medicine ■ Nurse practitioners ■ Physician assistants ■ Clinical nurse specialists ■ Nurse anesthetists ■ Clinical psychologists ■ Physical therapists ■ Occupational therapists ■ Qualified speech-language pathologists ■ Qualified audiologists ■ Registered dietitians or nutritionists ○ These MIPS eligible clinicians are automatically excluded from reporting requirements and payment adjustments if: ■ They are in their first year of Medicare ■ They are Qualifying APM Participants (defined later) ■ They do not meet or exceed the “low-volume threshold” ○ The low-volume threshold is also subject to change per CMS discretion

■ The low-volume threshold finalized for the 2019 performance year and beyond excludes MIPS eligible clinicians/groups who (during the determination period) ● Have less than or equal to $90,000 in Part B allowed charges for covered professional services ● Provide care to less than or equal to 200 Part B-enrolled patients ● Provide less than or equal to 200 covered professional services under the Medicare Physician Fee Schedule (MPFS) ○ Beginning in 2019, MIPS eligible clinicians or groups can opt into the program if they meet or exceed at least one (but not all three) of these criteria ■ Those who opt in are held to the same reporting requirements and payment adjustments as everyone else in the program ○ As an alternative to opting in, clinicians who are not eligible to participate in MIPS (they do not meet or exceed all three criteria) may voluntarily report quality data to CMS ■ Volunteers do not qualify for +/- adjustments, they do receive a performance feedback report from CMS ■ Clinicians/groups can use this report to assess their performance and prepare for future participation in either MIPS or and Advanced APM Submitter Types ● MIPS eligible clinicians - now referred to as submitter types - may submit data on measures and activities to CMS: ○ As an individual ○ As a group ○ As a virtual group ○ As an APM entity Submission Types ● Submitter types submit data on measures and activities using CMS-approved submission mechanisms - referred to as submission types ● There are several ways individual and group reporters can submit MIPS data to CMS ○ Including direct, log in and upload, log in and attest and Medicare Part B claims ● CMS proposes to remove the CMS Web Interface as a collection type and submission type for groups and virtual groups beginning with the 2021 performance period ○ Certain restrictions apply ■ EX: beginning with the 2019 performance year, only small practices (<15) may submit quality data via Medicare Part B claims, and only groups of 25 or more clinicians may submit data via the CMS Web Interface ● The MIPS performance year (when data is collected) is January 1 through December 21. ○ Participation providers must submit their data to CMS between Jan 1 and Mar21 following the performance year using the appropriate submission type Collection Types ● Collection types are quality measure sets with comparable specifications and data completeness criteria such as electronic clinical quality measures (eCQMs), MIPS clinical quality measures (CQMs), qualified clinical data registry (QCDE) measures, Medicare Part B claim measures, CMS Web Interface measures, the Consumer Assessment of Healthcare Providers & Systems (CAHPS) for MIPS survey measure, and administrative claims measures ● Collector types may use a combination of collection types to submit their data (some restrictions) ● Collection types are delineated by the four MIPS performance categories ○ Quality ■ Goal is to assess the value of care to ensure patients get the right care at the right time ■ MIPS eligible clinicians, groups must submit at least six quality measures for the 12- month performance period ■ Each measure is worth a maximum of 10 points for a max of 60 achievement points ■ Note: the way in which measures are scored is rather complicated and beyond scope of this course ○ Promoting Interoperability

■ Goal: promote the secure exchange of health information and the use of certified electronic health record technology (CEHRT) for coordination of care ■ As with the other categories, each measure in the PI category is now scored based on the MIPS eligible clinician’s performance for that measure, based on the submission of a numerator or denominator, or a yes or no submission ● The scores for each of the individual measures are added together to calculate a scope of up to 100 possible points ■ The four objectives and measures are: ● ePrescribing ● Health information exchange ● Provider to patient exchange ● Public health and clinical data exchange ■ Clinicians are required to report measures from each of the four objectives for 90 continuous days, unless an exclusion is claimed from this category ● In addition to submitting measures, clinicians must: ○ Submit a “yes” to the Prevention of Information Blocking Attestation ○ Submit a “yes” to the ONC Direct Review of Attestation ○ Submit a “yes” for the Security Risk Analysis ■ PI measure data can be attested on QPP.CMS.GOV ■ In 2018, providers had 2 options based on the provider’s EHR edition: ● 1. Program Interoperability Program Objective and Measures ● 2. Program Interoperability Program Transition Objectives and Measures ■ As of 2019 performance period, Option 2 is no longer an option ● 2015 Edition CEHRT is now required for all reporters ● Clinicians/groups can apply for a PI Hardship Exception if one of the following situations applies: ○ MIPS eligible clinician in a small practice (<15) ○ MIPS eligible clinician using decertified EHR technology ○ Insufficient internet connectivity ○ Extreme and uncontrollable circumstances ○ Lack of control over the availability of CEHRT ○ Improvement activities ■ Goal: promote practice access, population management, care coordination, beneficiary engagement, patient safety and practice assessment, participation in an APM, health equity, emergency preparedness and response, and integrated behavioral and mental health ■ There are ~90 measured activities that are designed to prompt such improvements ● High-weighted activities are worth 20 points and medium-weighted activities are worth 20 points and medium-weighted activities are worth 10 points each ● clinicians/groups that hold special status (small practices, non-patient facing, rural, and Health Professional Shortage Area) received double points for each activity ● To earn full credit in the performance category, participants must perform for 90 continuous days a combination of improvement activities that equal 40 achievement points ● Can attest improvement activities at QPP.CMS.GOV ○ Cost ■ Goal: create efficiencies in Medicare spending ● No reporting/data submission is required ● CMS analyzes data from both Part A and Part B claims to calculate the overall cost of patient care ■ Cost measures assess a patient’s total cost of care during the year or during a hospital stay and/or during certain episodes of care ● All clinicians/groups are evaluated on the same cost measures, which include:

○ Total per Capita Cost Measure ○ Medicare Spending per Beneficiary ○ Episode-based measures ● Episode-based measures are categorized into two groups ○ Procedural - measure specifications only include items and services that are related to the episode of care for a specific clinical procedure ■ EX: elective outpatient percutaneous coronary intervention, knee arthroplasty, revascularization for lower extremity chronic critical limb ischemia, routine cataract removal with intraocular lens implantation, and screening/surveillance colonoscopy ○ Acute Inpatient Medical Condition group ■ Measure specifications only include items and services that are related to a specific condition ● EX: intracranial hemorrhage or cerebral infarction, simple pneumonia w/ hospitalization and ST- elevation myocardial infarction w/ percutaneous coronary intervention ■ Achievement points for Cost measures are determined by comparing performance to a benchmark created using performance data from the performance period MIPS Final Score ● Each Performance category carries a certain amount of weight in the MIPS final score ○ The weights of Quality and cost have changed each year as MACRA requires the cost category to be 30% of the MIPS final score by performance year 2022 ■ CMS is implementing that in requirement in phases

● The higher the MIPS final score, the higher the payment adjustment ○ If you know the total points earned for each category, you can use AAPC’s MIPS Score Calculator to calculate your MIPS final score Advanced Alternative Payment Models (APM)

● An APM is a group of clinicians who have voluntarily come together in an organized way to deliver coordinated high-quality care to Medicare patients, ○ Advanced APM entities agree to: ■ Use of certified EHR technology (must be certified under 2015 criteria) ■ Base payment on quality measures comparable to MIPS ■ Either bear more than nominal risk for financial losses or is a Medical Home Model expanded under CMS Innovation Center authority ● Advanced APMs include: ○ Bundled Payments for care Improvement advanced; Comprehensive End Stage Renal Disease Care - two- sided risk; Comprehensive Primary Care Plus, and others ● MIPS eligible clinicians who are on the participation list of one or more Advanced APMs during a determination period (snapshot) are not required to report MIPS data ○ They may also qualify for a 5% incentive if they achieve threshold levels of payments or patients through an Advanced APM or the All-Payer and Other Payer option ■ Snapshot dates are March 31, June 30, and August 31 ● As an added incentive, Qualifying Participants of Advanced APMs will receive a single conversion payment factor of 0.75% beginning in 2024, whereas all other clinicians will receive 0.25% ● To date, eligible clinicians in a MIPS APM are required to participate in MIPS through their APM entity under the APM Scoring Standard ○ In the 2021 PFS proposed rule, CMS proposes to discontinue the APM Scoring standard beginning with the 2021 performance period The Need for Compliance Rules and Audits ● All provider offices and healthcare facilities should have, and actively use, a compliance plan ○ A compliance plan is a written process for coding and submitting accurate claims ○ Includes mechanism for detecting and correcting claim errors ○ A Compliance plan may offer several benefits, among them: ■ Faster, more accurate payment of claims ■ Fewer billing mistakes ■ Diminished changes of a payer audit ■ Less change of violating self-referral and anti-kickback statutes ● Additionally, the increased accuracy of provider documentation that may result from a compliance program may assist in enhancing patient care ○ Compliance programs show the provider practice is making a good faith effort to submit claims appropriately and sends a signal to employees that compliance is a priority ○ It should also provide a means to report erroneous or fraudulent conduct, so that it may be corrected ○ The Patient Protection and Affordable Care Act, makes compliance plans mandatory as a condition or participation in federal healthcare programs, ■ However there is not yeat an implementation date for the mandatory compliance ● The Office of Inspector General (OIG) - a government agency tasked “to protect the integrity of HHS programs, as well as the health and welfare of the beneficiaries of those programs” - offers compliance program guidance to form the basis of a voluntary compliance program for a provider practice ○ The OIG Compliance Program Guidance for Individual and Small Group Physician Practices was published in the Federal Register on 10/5/ ○ This document remains appropriate guidance for compliance in provider offices today ● The seven key components of an effective compliance plan include: ○ Conducting internal monitoring and auditing through the performance of periodic audits ■ This ongoing evaluation includes not only whether the provider practice’s standards and procedures are current and accurate, but also whether the compliance program is working ● (For EX: whether individuals are properly carrying out their responsibilities and claims are being submitted appropriately) ○ Implementing compliance and practice standards through the development of written standards and procedures ■ After the internal audit identifies the practice’s risk areas, the next step is to develop a method for dealing with those risk areas through the practice’s standards and procedures

■ Written standards and procedures are a center component of any compliance program ■ Those standards and procedures help to reduce the prospect of erroneous claims and fraudulent activity by identifying risk areas for the practice and establishing tighter internal controls to counter those risks, while also helping to identify any aberrant billing practices ○ Designating a compliance office or contact(s) to monitor compliance efforts and enforce practice standards ■ Ideally, one member of the staff needs to accept the responsibility of developing a corrective action plan, and oversee adherence to that plan ■ This person can either oversee all compliance activities for the practice or play a limited role merely to resolve the current issue ○ Conducting appropriate training and education on practice standards and procedures ■ Education is important to any compliance program ■ Education programs are tailored to the provider practice’s needs, specialty and size including both compliance and specific training ○ Responding appropriately to detected violations through the investigation of allegations and disclosure of incidents to appropriate government entities ■ It is important that the compliance contact or another employee look into possible violations and takes decisive steps to correct the problem ● Such steps may involve a corrective action plan, the return of any overpayments, a report to the government and a referral to law enforcement authorities ○ Enforcing disciplinary standards through well-publicized guidelines ■ The OIG recommends that a provider practice enforcement and disciplinary mechanisms ensure that violations of the practice’s compliance policies will result in consistent and appropriate sanctions, including the possibility of termination, against the offending individual ● This is a highly condensed summary of the OIG’s recommendations ● The scope of a compliance program depends on the size and resources of the provider practice ○ As a means to implement a compliance program, the OIG encourages providers to participate in other compliance programs, such as the compliance programs of the hospitals or other settings in which they practice ○ Practice Management companies also may serve as a source of compliance program guidance The OIG Work Plan ● The OIG work plan sets forth a plan outlining its priorities for the fiscal year and beyond ○ The OIG posts its continuing work planning efforts on its website and updates the projects monthly ○ Some of the projects described in the work plan are statutory required, such as the audit of the department’s financial statements, which is mandated by the Government Management Reform Act ○ Of special interest to Healthcare, the work plan identifies potentially noncompliant areas the OIG intends to scrutinize