Imaging Creates Smart Dashboards By Jeff Maze

Transcription

1 Table of Contents Imaging Creates Smart Dashboards Succession Planning for Radiology Practices Five Best Practices in Data Security ICD-10 Deadline 2015 MPFS Proposed Rule Highlights PET Coverage Update Critical Elements of HC Reform Implementation Omnirad Enters Into New Billing Agreement with Zotec Zotec Hires Mark Scruggs Imaging Creates Smart Dashboards By Jeff Maze Radiologists face a gamut of industry and legislative developments that challenge their hospital relationships and their managed care reimbursement agreements and the fierce imaging center competition that comes with them. Along with rising health care costs and declining reimbursements, radiology administrators are encountering new obstacles as they witness changes and maturation in digital technology. It's becoming increasingly more important to obtain timely information, presented visually, and to provide usability throughout the entire organization. In addition, drilling down into practice data to discover more detailed information in an ad hoc manner is critical to empowering radiologists in the decision-making process. While monitoring and managing day-to-day operations of a radiology department, such as workflow, throughput, report turnaround times, or exam volume, remain vital to quality improvement, the importance of them is still often provided via retrospective static reporting. A key challenge facing radiologists will be transitioning away from the comfort of familiar static (and stale) tabular reporting into the new world of real-time interactive dashboards that perform complex analysis and visualizations all day, every day. Ongoing Advancement There's no doubt that health care technology for business is advancing rapidly. Business intelligence dashboards, known as executive information systems, were born roughly four decades ago in health care. These systems had a basic foundation that centered on condensing data, typically revolving around an industry's key performance indicators, into a single-screen form for high-level decision

2 making. The static interface and nonintegrated usability were drawbacks to these prehistoric dashboards, and their inability to help with executives' rapid decision-making needs led to their eventual demise. Interactive dashboards were the next development, created out of executive information systems' shortcomings. These more advanced dashboards offered the benefits of enhanced visuals and usability, which empowered physicians at different levels with greater decision-making tools. The technology has evolved today, with the ability to stream and integrate information from various health care systems by consolidating the data into warehouses that can be accessed and manipulated to create valuable information and powerful dashboards. In other words, the history of executive information systems and interactive dashboard systems has paved the way for today's dashboard applications, which are visual and rich in information and can provide rapid access to real-time information. The functional features in dashboards can package information needed for short- and long-term decision making into graphs, charts, tables, dials, and other formats. This provides physicians and managers with a keener understanding of their practices' business side and trends. With detailed summaries and data analysis, physicians receive their electronic information rapidly throughout the entire organization. Dashboard Customization However, not all dashboards are equal. The radiology practice dashboard should be tailored to meet the unique needs of a radiology business, where practices can define goals and form a vision as they create their business model. For customization, radiology practice leaders must consider the daily, weekly, and long-term information and comparisons needed to make strategic decisions, including the following: monthly run rate against targets for charges and reimbursements; key accounts receivable metrics against targets, such as days in accounts receivable, accounts receivable percentage over 120 days, adjusted collection percentage, and bad debt with trending and historical information; modality information, such as volumes, charges, and reimbursements by modality or CPT; sorting available on a click-on basis by top charges, payments, or collection percentage; and links to corresponding procedure analysis reports online; payer mix information, such as reimbursements by payer with volumes, charges, and reimbursements for each payer as well as numerous selection criteria for specific payers; referral information, such as top 10 referring physicians by total volume or the top 10 referring physicians by lost volume; managed care contracting; and physician productivity. Key performance indicators, which serve as benchmarks for data aggregation and analysis, are critical pieces of business intelligence. However, simply setting them isn't enough. Practices should focus on setting realistic and achievable goals while making a point to review frequently to ensure they're still accurate. Inaccurate or outdated key performance indicators can do more damage to a practice than simply not having them set in the first place, since users can become numb to the

3 constant variances and discrepancies and be less likely to spot an actual issue when one arises. Advanced functional capabilities also are important. These capabilities include the ability to drill down into the details, save custom views and settings, allow for commenting and collaboration inside the tool, and access to historical financial reports. Radiologists who can see graphical and numerical trending across their practice, with the ability to rapidly filter and sort the information, can get a big picture view of what decisions must be made. These capabilities also impact integration with other facilities and systems, including mission-critical RIS and scheduling systems. In conclusion, advanced dashboard applications are one of the biggest weapons radiologists have against rising health care costs and declining reimbursements. These dashboards should reflect a practice's unique business strategies and meet its varying and individual needs. While visually pleasing graphics and flashy dials may be a draw, practices should make sure they trust the information being presented and ask themselves what empowers them to make timely decisions to ensure long-term financial success. Jeff Maze is director of business intelligence for Zotec Partners.

4 Succession Planning for Radiology Practices By David Myrice, CPA, MBA The most common approach to succession planning among radiology practices is no approach at all, because the reality is that most of the radiology groups have no plan in place for when their leadership retires. Like most professional corporations, the owners are also the workers, which makes planning more complex and emotional. As a result, too many radiology groups are just operating on the fly. A widely held misperception regarding succession planning is that it focuses solely on new leadership, when, in fact, incoming leadership represents just half of the equation. Succession planning is both how you train your future leaders and how you treat your departing leaders. Do you have the ability to accommodate older members of your practice as they are winding down? When it comes to your younger people, how do you address the disparities between your goals? Deciding on an exit strategy for departing leadership is as important as how you groom new leadership coming up. You want to establish processes and policies while everyone is happy, and stick to them. Disparities in Goals The disparities in goals referenced above include both generational differences and differences inherent to radiologists professional timelines. Generational differences are well-trod territory: younger radiologists tend to be more invested in maintaining work-life balance, making them more amenable to lifestyle-enhancing decisions like outsourcing night and weekend call or even moving to hospital employment. A lot of your younger radiologists coming out of medical school are very lifestyle-structured. They want to make the same income as their older colleagues, but they never had that experience of having to work all night long. They also never had to deal with everyone sitting in the reading room together, popping films up onto the viewer. Technology has changed a lot of perceptions of where the profession is going. Lest the blame for disparities be placed solely on the shoulders of the younger generation, it should be stressed that the older generation can also be tempted to put its priorities ahead of the good of the group. For instance, traditionally, senior radiologists are running the group, and they have the experience and the knowledge, but their goals have changed over time. They are willing to ride things out they do not want to rock the boat. The younger generation is looking at the future and feeling nervous. In short, there is a catch-22 inherent to handing over the leadership reins, caused in no small part by health care s current instability. The older people have to be willing to step down and train the younger people to come forward, but the younger people have to keep in mind that their long-term goals will not always match up with the older generation s goals. There is no easy answer for it. Structured Approach For that reason, as radiology groups are advised to take a formal, structured approach to succession planning, setting policies and procedures in advance and sticking to them. First, current leadership should identify the type of leader they believe the group needs in the future based on their experience and knowledge. Groups should determine which people are the right fit for what is

5 needed down the line, identify them, and assess their level of interest. Most radiologists did not set out on careers in medicine with the intention of becoming business leaders, so practices should invest in supplementary training for their future leaders. You want to mentor them, test their capabilities, even send them to a few leadership courses on the corporation s dime. Involve them over time and groom them for their future roles. As opportunities present themselves to involve them on a more formal basis becoming a member of the board, accompanying current leadership during hospital administration meetings take advantage of them. The specialty of radiology is recognizing the need to develop leaders in the challenging environment of healthcare management. The ACR recently implemented the Radiology Leadership Institute (RLI) to prepare radiologists with critical leadership skills for advancing in practice leadership and strengthening the radiology profession. Meanwhile, the group should decide on a policy for outgoing members. An example is the older radiologist who wants to transition to working part-time. Most groups really cannot afford to maintain a partner on a part-time basis. On the other hand, the older members of the group are the ones with the relationships with hospital administration, so there is a value to transitioning them out slowly. Maybe the group will decide that radiologists can work part-time, but lose their voting rights. The ideal scenario is the group comes together before the question is raised to decide whether they will allow people to slowly taper off, or whether their retirements will be abrupt endings. In initiating the succession planning process, members of radiology groups would be well advised to remember that every vote they take will be taken personally. Any vote you take, most people are looking at it from the perspective of how it will affect them. If you want good leaders, you need to groom them to be good leaders, but you also want to show how well you treat the people who were leaders when they are on the way out. If you decide in advance what the rules are and stick to them, you will have an easier time down the line. David Myrice, CPA, MBA, is director of practice management for Zotec Partners.

6 Five Best Practices in Data Security: Protect Patient Privacy, Avoid Group Risks By Ned Campbell In an age where health care technology platforms continue to evolve and in which the vast majority of patient information is transmitted and maintained electronically, data security and privacy continue to be a major concern among imaging providers. While a company s data security and privacy practices and policies are often designed to meet the strict standards established by the Health Insurance Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health Act (HITECH), health care organizations often fail to practically guard themselves against their greatest risks of unauthorized disclosure of protected health information (PHI) and electronic PHI (ephi). By taking five simple actions, practices can not only ensure their patients privacy and security, but can also protect their practice s reputation and reduce exposure to potential fines and lost customers that often accompany incidents involving theft, loss or other unauthorized disclosures of PHI. Educate and Reinforce Ongoing education of company employees is the most important investment a practice can make in security and privacy. Employees who are not only trained in HIPAA security and privacy standards and practices, but also understand the risks they are trying to mitigate, serve as a company s best line of prevention. Providing security and training above and beyond the annual education requirements and communicating security reminders frequently through the year are two effective means of building a workforce that is sensitized to data security matters. It is also important to make sure employees understand the information and are not just glancing over it. In this regard, quizzing employees at the end of a training session is an effective way to make sure they understand the material. Encrypt Everything Though many radiology practices may be well versed in protecting the privacy of patient information, they may be less familiar with ensuring the security of patient information. While it is a common practice to deploy encryption services to protect PHI while it is in motion, practices may be less familiar with actions they can take to protect PHI while it is at rest. The largest amounts of PHI are often not included in a single , but instead reside on data storage devices. Generally speaking, all data should be encrypted (not just password protected) whether it is data in motion or data at rest. Not only laptop hard drives should be encrypted, but also portable USB (thumb) drives, external hard drives, backup drives and desktop computers on which data is stored. Travel Smart Employees who travel often take with them PHI on the go. Traveling employees pose one of the greatest risks to data privacy and security for a company. Laptops, smartphones and thumb drives can all contain large amounts of private and sensitive information. In addition to having encryption protection on these devices, employees need to be vigilant to protect them from being misplaced or stolen. These types of devices should remain in the personal possession of the traveler or be

7 appropriately secured and powered down when not in use. They should not be checked as luggage, left in a car (unlocked, locked, or in the trunk) or left unsecured in a hotel room. As Benjamin Franklin said, An ounce of prevention is worth a pound of cure. Outsmart Hackers In another area of security risk management, employees should also be aware of and sensitive to hackers. Employees need to be educated in how hackers operate through phishing and spoofing schemes. These threats to a practice s data come faster than virus protection and spam filters can prepare for, and therefore it is critical to constantly educate on these matters. Practices need to develop procedures and educate their employees on what to do if they receive suspicious s they may otherwise believe to be legitimate that ask for their name, username, password, date of birth, Social Security number or other personal information. Strengthen Passwords Passwords can now be hacked more easily than ever before. To strengthen controls around unauthorized access to data, practices should implement security protocols with strict requirements that computer passwords be changed after a certain length of time. It is also ideal to make sure passwords are very strong at least eight characters, one number, one capital letter and at least one additional symbol. Data stored on hard copy, meanwhile, needs to be secured the old-fashioned way under lock and key. In closing, data security should be a top priority that is always taken very seriously. Following best practices through a comprehensive data security and privacy plan will ensure a tight ship on all patient and provider data, which gives everyone the utmost peace of mind and privacy while avoiding the publicity of a data breach and dangerous compliance risks. Ned Campbell is chief compliance officer of Zotec Partners.

8 ICD-10 Deadline Set for October 1, 2015 The U.S. Department of Health and Human Services (HHS) issued a rule on Thursday, July 31, 2014 finalizing October 1, 2015 as the new compliance date for health care providers, health plans, and health care clearinghouses to transition to ICD-10, the tenth revision of the International Classification of Diseases. This deadline allows providers, insurance companies and others in the health care industry time to ramp up their operations to ensure their systems and business processes are ready to go on October 1, Zotec Partners remains ready for the ICD-10 adoption and will continue to work closely with its provider clients on planned ICD-10 efforts. Now that CMS has finalized the deadline, Zotec will update its transition timelines accordingly, to ensure its clients are fully prepared for the transition. Additional references: (1) (2) =RealMagnet&utm_medium= &utm_campaign= (3) ZldCbkJiYkY0M3hlMFNxamtVY0NPVT0=&utm_source=link NEWS &utm_med ium= &utm_campaign=hits-alert

9 Radiology Highlights and Summary: 2015 MPFS Proposed Rule By Missy Lovell, BSN, RN, MBA and Lonnie Johnson, MBA The following pages contain radiology specific highlights and summary on CMS Proposed Final Rule for the Medicare Physician Fee Schedule (MPFS) that was originally published on July 11, CMS will accept comments on the proposed rule until September 2, 2014, and will respond to them in a final rule to be published in early November 1, Reduction in the Conversion Factor There is a zero percent update mandated from January 1, 2015 to March 31, 2015 leaving the current conversion factor (CF) of $ , minimally changed during that time. Unless Congress intervenes prior to April 1, 2015, then a percent update to the current CF will be applied at $ Proposed Fee Schedule Calculation Provisions and Estimated Impacts Based on RVU changes and other proposed provisions of the 2015 fee schedule, CMS estimates a -2% impact for radiology; interventional radiology is estimated to be impacted to a lesser degree at -1%. Radiation oncology (RO) and radiation therapy centers (RTC) bore the largest estimated impact mainly due to the PE input revisions associated with radiation treatment vaults; those overall impacts are estimated at -4% and -8% respectively. All estimated specialty impacts are exclusive of any change to the current CF. 3. Review of Potentially Misvalued Codes, RVU PE and Input Proposals CMS identified 65 codes as being potentially misvalued based on their high level of Medicare expenditures. Of those listed approximately 25+% relate to radiology and other radiology services have been earmarked for review through other nomination processes. Other proposals relate to the gradual phase out of ten (10) and 90 day global packages, respectively, into zero (0) day global packages, respectively, over 2017 and 2018 which would allow separate billing for medically necessary pre-op and post-op services as applicable Based on the RUC s recommendation that all imaging codes, including mammography, be valued using digital rather than film inputs as film is no longer typical, CMS proposes to reapply digital inputs and omit the film and related direct inputs to the PE RVUs of various imaging services. As a result, the digital mammography G-codes are proposed to be deleted and the mammography CPT codes retained; the current digital code RVUs will be used until they can go through the misvalued process. Radiation oncology/centers felt the brunt of PE input changes as they propose to remove the radiation treatment vault as a direct PE input from a list of 14 radiation treatment procedures and move it to an indirect PE. There are other RVU PE change and misvalued proposals as well as MP RVU revisions that will directly or indirectly affect radiology. Geographic Practice Cost Indices (GPCIs) GPCIs are used in the RBRVS formula to measure resource cost differences among localities compared to the national average for each of the three RVU components holds the second year of a phase-in of revised GPCI s and the work GPCI floor of 1.0 is currently in place through the end of March 2015; this floor is set to expire again at that time and the 2015 proposed rule holds GPCI addenda that include January March 2015 GPCIs and April December 2015 GPCIs. Off-Campus Provider Based Departments and Physician Services CMS proposes to collect data to analyze the frequency, type and payment for services furnished

10 in off-campus provider based departments through the use of a HCPCS modifier. CMS is proposing that a modifier be reported for off campus services, e.g., physician s offices, provider based departments of hospitals where the billing of these off campus sites of service include both professional and facility fees. This modifier is to be reported with every code for physician and hospital services furnished in an offcampus provider based department of a hospital, both on the 1500 and UB-04, and seek input on the use of a modifier for that purpose. Payment of Secondary Interpretation of Images CMS is seeking specific provider input regarding the provision of secondary interpretations which stems in part from concerns that providers may have regarding uncertainty of payment for secondary interpretations. CMS seeks to better understand under what conditions those secondary services are needed and how best to address these services to, among other things, potentially avoid duplicative studies being performed. Solicitation of Comment on the Payment Policy for Substitute Physician Billing Arrangements In general there is an allowance for two types of substitute physician billing arrangements, reciprocal billing and locum tenens billing. Based on various concerns mentioned in the proposed rule, they seek provider comment on specific substitute physician questions to analyze the need for any changes to existing regulation Physician Quality Reporting System The 2015 PQRS program moving forward will no longer provide incentive payments for successful participation and concurrently lack of participation and/or successful reporting can earn the providers an adjustment in 2017 and forward. The 2015 PQRS reporting will determine whether or not the EP or group gets assessed a -2% PQRS adjustment in 2017; therefore if a provider does not meet the criteria CMS sets in place for successful reporting and participation in 2015, the EP will see their services paid at 98.0% of the allowable in CMS proposes some changes to the existing reporting criteria as outlined in the proposed rule. Value Based Payment Modifier (VBM) The VBM originated in the Patient Protection and Affordable Care Act (PPACA), and will lead to potential payment adjustments based on a comparison of physicians cost and quality. The 2017 VBM adjustment will be based on 2015 PQRS reporting criterion and is proposed to be assessed on groups with two (2) or more EPs and solo practitioners, which would now meet the mandate that all physicians be applicable to the VBM by Other proposed changes will apply the VBM adjustment in 2017 to all physician and non-physicians practitioners (NPPs) in an eligible group and to double the VBM adjustment potential from They propose a -4% VBM adjustment potential for those groups who do not qualify for quality tiering. Reports of Payments or Other Transfers of Value to Covered Recipients (Open Payments Sunshine Act) The Open Payments program was developed in response to the Sunshine Act, and according to CMS promotes transparency by publishing data on the financial relationships between the healthcare industry and healthcare providers on a website for public inspection, essentially it requires drug and device companies to disclose payments to physicians. Physicians currently have a small window of opportunity (through August 27, 2014) to review industry supplied data and dispute it prior to being publicly available on September 30, 2014 (as described in the detail section below) and physicians are advised to review the website for their information if applicable so they have ample time for dispute as necessary. The recently released rule also proposed some changes to the Open Payments program.

11 Radiology Summary Details 2015 Reduction in the Conversion Factor The Protecting Access to Medicare Act of 2014 (PAMA) provides for a zero percent update from January 1, 2015 to March 31, The zero percent update and adjustments necessary to maintain budget neutrality from policies proposed in this rule result in an estimated conversion factor of $ for the first three months of If Congress fails to act to avert mandated SGR-related cuts prior to April 1, 2015, then a percent update will be applied to the conversion factor Proposed Fee Schedule Calculation Provisions and Estimated Impacts The following tables illustrates CMS estimates regarding the following impacts per selected specialties of all of the provisions included within the 2015 proposed fee schedule and the individual RVU component impacts (does not include the impact of the negative CF change/sgr per current law). **Shows the payment impact on PFS services and does not include the effects of the change in the CF scheduled to occur on April 1, 2015 under current law. Shown below are the impacts associated with select procedures (based on the March 2014 Preliminary Physician Update) as published in Table 61 of the 2015 proposed rule. The impacts do not include the effects of the change in CF scheduled to occur on April 1st of As a reminder when reviewing the 2015 payments on the table below, the mammography CPT codes and for CY2015 now contain the RVU s that were applicable to the 2014 digital mammography codes (i.e., G0202, G0204), as they found that use of digital technology is the standard and the 2014 payment rates for and were reflective of film technology inputs. All CY2015 mammography services (whether film or digital) will be paid at the digital input rates as they revalue those codes through the misvalued code process.

12 Review of Potentially Misvalued Codes, RVU PE and Input Proposals Input Changes Based on the RUC s recommendation that all imaging codes, including mammography, be valued using digital rather than film inputs as film is no longer typical, CMS is proposing to reapply digital inputs and omit the film and related direct inputs to the PE RVUs of various imaging services. Specifically for mammography, which has separate codes for film mammography services (i.e., 77055, and 77057) and for digital mammography services (i.e., G0202, G0204 and G0206), CMS believes that the typical mammography service is furnished using digital technology. In light of their findings that the mammography CPT codes are billed infrequently (the film codes), CMS proposes to delete the G-codes for 2015 and to pay all mammography using the CPT codes. CMS has also proposed the inclusion of a new direct PE input of a standard supply package for contrast enhanced imaging. This takes into account all of the auxiliary items needed to administer contrast and is included in the PE RVU of those test services. For radiation oncologists and therapy centers, the revision of the treatment of the radiation treatment vault in the PE inputs drastically impacted estimated payment amounts as follows (according to the ACR): this is mainly because CMS proposes to treat radiation treatment vaults as indirect practice expense (PE) rather than direct PEs. Specifically, in previous rulemaking, CMS questioned whether it was consistent with the principles underlying the PE methodology to include the radiation treatment vault as a direct cost given that it appears to be more similar to building infrastructure costs than to medical equipment costs. Moreover, it is difficult to distinguish the cost of the vault from the cost of the building. However, upon review of the information received, CMS believes that the specific structural components required to house the linear accelerator are similar in concept to components required to house other medical equipment such as expensive imaging equipment. Therefore CMS believes that the special building requirements indicated for the radiation treatment vault to house a linear accelerator do not

13 represent a direct cost in their PE methodology, and that the vault construction is instead accounted for in the indirect PE methodology, just as the building and infrastructure costs are treated for other PFS services including those with infrastructure costs based on equipment needs. Therefore, CMS proposes to remove the radiation treatment vault as a direct PE input from a list of 14 radiation treatment procedures, because CMS believes that the vault is not, itself, medical equipment, and therefore, is accounted for in the indirect PE methodology. Potentially Misvalued Codes Attached is the list of potentially misvalued codes that were identified through the high expenditure specialty screen and CMS would ask for provider input; they would assess changes in physician work and direct PE inputs for the services identified on the list and revalue as applicable. Additionally there were other services as noted below that they are also adding to the potentially misvalued list and would ask for provider comments. Epidural Injection and fluoro guidance 62310, 62311, and 77001, In 2014, CMS applied interim RVU values for the epidural injection codes and received many comments on the decreases for those services. CMS is now proposing to reinstate the 2013 RVU values for those codes in 2015 and will reassess the inputs for those services. They also noted that fluoro was typically billed along with those services and several similar services had the fluoro bundled. So concurrently they are also proposing that fluoro will now be bundled into these services and propose to disallow separate billing for the fluoro. Mammography codes , and HCPCS G0202, G0204 and G0206 As described above, CMS is proposing elimination of the digital HCPCS codes and the CPT mammography codes will be used to bill for all mammography services as digital has become the prevalent mode of providing mammography services. Concurrently, they will apply the Gcode RVUs to the CPT codes to ensure digital inputs are captured. As the G-code RVUs have not been reassessed since 2002, they propose to put the CPT mammography codes on review as potentially misvalued. Abdominal Aortic US Screening G0389 When G0389 was first valued it was crosswalked to 76775; in 2014, underwent a revaluing and the PE direct units were decreased which affected the RVUs for G0389. Many commenter s stated that G0389 was dissimilar to 76775; in response CMS will reinstate the 2013 RVU s for G0389 and add it to the list of potentially misvalued codes and seek provider input. Valuation and Coding of the Global Package CMS reiterates that there are three categories of global packages labeled based on the number of post-op days included in the global period: zero (0), ten (10) and 90-day. CMS then essentially bundles the pre-op, intra-op, and post-op visits, postsurgical pain management by the physician, and supplies (except for those excluded) into the global surgical package. CMS has not reassessed these packages since this global package was first established 1992, and realizes that there are

14 some apparent fundamental flaws with this current packaging of services to include the following: They were established several years ago when FU care was more homogenous; There is much more diversity in the kind of procedures covered by global periods, setting and the FU care that is provided; The care needs of beneficiaries has evolved; and Payment, for most bundled services, relies on valuing the combined services together; and there are no separate MPFS values for the procedures or the FU care, making it difficult to estimate the amount of each. They also note throughout their discussion that providers may furnish a wide range of post-op services depending on patient need, changes to medical practice, and the number of visits may vary greatly per case. CMS also cited two OIG reviews in which they noted that based on each sample there was not as many E/M services provided as were included within the bundled global package(s). According to the Part B News, July 14, 2014, there are 3,799 codes with the 90-day global period and 473 codes with the ten (10)-day global. Experts believe that CMS will also request future comments on how the surgical codes should be re-valued, assuming no global period concept applies. To address these issues and disparities, CMS is proposing to currently retain global packages for surgical services, but to refine them by transitioning over several years all ten (10) and ninety (90)-day global codes to zero (0)-day global codes. Medically reasonable and necessary visits would be billed separately outside of the day of the surgical procedure. The proposal includes making the transition for current ten (10)-day global codes in 2017 and ninety (90)-day global codes in 2018 pending the availability of data. Valuing Services that include moderate sedation as inherent in the Procedure CMS notes that the CPT manual includes more than 300 diagnostic and therapeutic procedures for which CPT has determined that moderate sedation is an inherent part of furnishing the service and therefore only the procedural service is billed. Due to changing medical practice, many of those categories of services now have a separate anesthesia charge billed in addition to the procedures. CMS is asking for comments on approaches to valuing those 300+ codes that would allow them to pay accurately for moderate sedation when furnished and avoid duplicate payments when a separate anesthesia service is furnished and billed. Malpractice RVUs (MP) CMS is required to review, and if necessary adjust RVUs no less than every five years. CY 2015 will hold the third review and update to the MP RVUs. Keeping in mind that on average, the work RVU comprises 50.9% of payment for a service under the MPFS, the PE RVU about 44.8%, and the MP about 4.3%, most revisions to this RVU category will be minimally felt in comparison to other RVU changes. The newly revised MP RVUs are in Addenda B of the proposed rule. Geographic Practice Cost Indices (GPCIs) Section 1848 (e)(1)(c) of the Act requires CMS to review and, if necessary, adjust the GPCIs at least every 3 years; if more than 1 year has elapsed since the date of the last previous GPCI

15 adjustment, the adjustment to be applied in the first year of the next adjustment shall be half of the adjustment that otherwise would be made. Therefore, since the previous GPCI update was implemented in CY 2011 and CY CMS phased in half of the latest GPCI adjustment in CY 2014 and the 2015 GPCIs will hold the completed GPCI adjustments. GPCIs are used in the fee formula to measure resource cost differences among localities compared to the national average for each of the three RVU components. As a reminder, there is a permanent 1.5 work GPCI floor in place for Alaska which was initiated on January 1, 2009 and on January 1, 2011 a permanent 1.0 PE GPCI floor for frontier states was effected (Montana, Wyoming, North Dakota, Nevada and South Dakota). There was also a work GPCI floor of 1.0 in place for all localities which was set to expire in 2009 and ultimately got extended through the end of March This floor is set to expire again at that time and the GPCI addenda include January March 2015 GPCIs and April December 2015 GPCIs. This 1.0 work floor would have to be extended with congressional action. Off-Campus Provider Based Departments and Physician Services CMS notes that they would like to better understand the growing trend toward hospital acquisition of physician offices and treatment of those locations as off-campus provider based departments and how those affect payments under the MPFS and beneficiary cost-sharing. Assumedly this trend may be fueled from a desire to purchase physician offices and designate them as provider-based which allows the hospital to bill a facility fee in addition to the claims submitted by the physician providers to Part B. The industry and others have noted that in these situations, although the same professional services are supplied at the same locations, the payments can differ significantly in provider based departments versus physician office designations. CMS also notes concerns of increased beneficiary cost-sharing when physician offices become hospital OP departments and MedPAC (the non-partisan think tank that advises Congress on Medicare policies) has recommended that Medicare pay selected HOPPS services at MPFS rates. CMS opines that as more physician offices become hospital based, it becomes difficult to determine which PE costs typically are incurred by the physician, hospital or whether their site of service differential accounts for the typical resource costs. Based on these concerns, CMS feels that they should collect data that would allow them to analyze the frequency, type and payment for service furnished in off-campus provider based departments. They propose the use of a HCPCS modifier to be reported with every code for physician and hospital services furnished in an off-campus provider based department of a hospital, to be used on the 1500 and the UB-04 and seek comment on the modifier usage. Payment of Secondary Interpretation of Images According to CMS, questions have arisen as to whether and under what circumstances it would be appropriate for CMS to permit payment under the PFS when physicians furnish subsequent interpretations of existing images, and whether uncertainty regarding the payment of those inhibits providers from seeking out existing imaging where the avoidance of a new study would result in savings to Medicare. There is a list of questions that CMS is asking for provider input to include, for example: For which services are physicians currently conducting secondary interps and what policies are in place if any to determine when existing images are utilized?

16 Should routine payment for secondary interps be restricted to high-cost ADI services? Their goal is to seek provider input on conditions that require the performance of secondary interpretations in hopes to address policy to avoid the performance of duplicative studies. Solicitation of Comment on the Payment Policy for Substitute Physician Billing Arrangements CMS notes that in general they allow for two types of substitute physician billing arrangements; reciprocal billing, and locum tenens billing. CMS noted various concerns with the current billing policies to include: Operational and program integrity issues that result from the use of substitute physicians to fill staffing needs: Or to replace a physician who has permanently left a group and misunderstandings of who would alert the carrier when the physician left a group, which would mean the departed physician is left open with the group for an extended time. This means the departed physicians NPI may be used on claims concurrently with his/her new group and the departed group. Without acknowledgement of the substitute physician on the claim form for these services, Medicare lacks the knowledge of whether or not the substitute physician is enrolled in Medicare or holds the credentials necessary to provide services to Medicare beneficiaries. Because of these concerns they are seeking provider input on a series of questions for possible changes to existing regulation concerning substitute physicians Physician Quality Reporting System (PQRS) The PQRS has been in existence since 2007 and currently providers can participate as an individual eligible professional (EP) or as a group practice through the Group Practice Reporting Option (GPRO). The 2015 PQRS program moving forward will no longer provide incentive payments for successful participation and concurrently lack of participation and/or successful reporting can earn the providers an adjustment in 2017 and forward. The 2016 PQRS adjustment increased to -2.0% (based on 2014 participation) and 2015 PQRS reporting will determine whether or not the EP gets assessed a -2% PQRS adjustment in If an EP does not meet the criteria CMS sets in place for successful reporting and participation in 2015, the EP will see their services paid at 98.0% of the allowable in The 2015 reporting mechanisms are: claims-based reporting, qualified registry, EHR, the GPRO web interface, certified survey vendors and the Qualified Clinical Data Registry (QCDR). Some notable proposed changes include: If an EP chooses to report via a qualified registry or through the claims-based method, in addition to requiring that an EP or group practice report on at least nine (9) measures covering three (3) NQS domains, any EP or practice who sees at least one (1) Medicare patient in a face-to-face encounter must report on at least two (2) crosscutting measures as specified in the cross cutting measure list. If an EP reports through a QCDR, they have proposed to require that EPs report on nine (9)

17 measures (covering at least three [3] NQS domains) of which three (3) of those (or less if applicable) are outcome measures. The QCDR can now list 30 non-pqrs measures instead of the 20 they were held to in In summary, the criterion for EPs who choose to report individual measures via claims or a qualified registry are (for the 12 month reporting period of January 1, 2015 December 31, 2015): The EP would report at least nine (9) measures covering at least three (3) NQS domains and report each measure for at least 50% of the eligible instances. Of the measures reported, if the EP sees at least one (1) Medicare patient in a face-toface encounter, the EP would report on at least two (2) measures contained in the proposed cross cutting measure set. A face-to-face encounter will be determined by submitted codes, such as office visits, outpatient visits, surgical procedures, etc. (Telehealth visits would not be included in this definition.) If less than nine (9) are applicable, they would report on up to eight (8) measures and be applicable to the MAV process. If an EP chooses to report measures groups through a qualified registry, the EP would report during the 12 month period: At least one (1) measures group and report each measure group for at least 20 patients, (11 or more of which should be Medicare patients). Note: For 2015, there is no incentive as in prior years for success participation in a Maintenance of Certification (MOC) program. Value-Based Payment Modifier (VBM) The VBM originated in the Patient Protection and Affordable Care Act (PPACA), and will lead to potential payment adjustments based on a comparison of physicians cost and quality. The proposal is budget-neutral, so increases in Medicare payment rates for some physicians will be offset by reductions for others. The VBM will be applied to groups with 100 or more EPs in 2015, groups of 10 or more EPs in 2016 and to all physicians in The 2017 VBM adjustment will be based on 2015 criterion. The VBM program contains two primary components: The Physician Quality and Resource Use Reports (QRURs) Development and implementation of a Value-Based Payment Modifier (VBM) Historically the VBM adjustments that will be made per group are based on prior year s PQRS participation, and indirectly utilizes the EP s QRURs. The EP s successful participation in PQRS for 2015 significantly affects the VBM adjustment that may ultimately be seen in 2017, and their QRUR s will play a central role in the quality tiering adjustment that will ultimately be determined. In late summer 2014, CMS will make QRURs available based on care provided in 2013 to all groups and solo practitioners. The 2013 QRURs will display a group practice s quality and cost composite scores, which are used to calculate the VBM. For group practices of 100 or more EPs that elected

18 quality tiering, the 2013 QRUR will display the groups 2015 VBM adjustment. The 2017 proposed process is much the same but CMS outlined the following proposals regarding the VBM policies that will determine the 2017 VBM payment adjustment for EPs and groups: To apply the VBM to all physicians and non-physician EPs in groups with two (2) or more EPs and to solo practitioners in Mandatory quality tiering for groups that meet the criteria for satisfactory reporting of PQRS data via GPRO or if reporting individually have at least 50% of the group s EPs meet the criteria, or those who satisfactorily participate in a QCDR. The one distinction is that groups with two nine (2-9) EPs would be subject only to a neutral or upward quality tiering adjustment and groups with ten (10) or more would be subject to a downward adjustment also. As this is the first year that groups with two nine (2-9) are applicable to the VBM, this continues the gradual transition into the program. To increase the amount of payment at risk from -2% to -4% in To align the quality measures/reporting mechanisms for the VBM with those available under PQRS during the CY2015 performance period. Groups are increasingly becoming applicable to the quality tiering and are subject to an upward, neutral or downward adjustment and according to CMS have been provided, sufficient lead time to understand how the VM works and how to participate in PQRS. In late summer of 2014, CMS will distribute QRURs based on CY 2013 data to all groups of physicians and solo practitioners. This will contain performance information on the quality and cost measures used to calculate the quality and cost composites of the VBM and will show how all TINs would fare under the policies established for the VBM. Additionally it will provide information about the individually reported PQRS measures and the specialty-adjusted cost measures. In the summer of 2015, they will distribute the 2014 data and their hopes is that will provide adequate lead time for groups to better their understanding of the VBM adjustment potential and how to improve quality and costs as applicable. It is important to note that for 2015 and 2016, any VBM adjustment made will only be applied to physicians, but CMS is proposing (as this is at their discretion) to apply the adjustment in 2017 to all physician and non-physicians practitioners (NPPs) in an eligible group and the NPPs would be subject to the same VBM policies. Those NPPs under the TIN could include: physician assistants, CRNAs and nurse practitioners. CMS is proposing that groups who elect to continue to report individual measures via the claims based or registry method and who do not have 50% of their EPs successfully participate in PQRS and avoid the PQRS adjustment, will additionally get a -4% VBM adjustment for the group in 2017 (both physicians and NPPs). If more than 50% of their EPs successfully participate in PQRS and avoid the PQRS adjustment then they will move into quality tiering, which could afford them an upward increase, neutral adjustment or a downward adjustment although groups with two nine (2 9) EPs will be exempt from any downward quality tiering adjustment. CMS estimates that based on the quality tiering data from 2012 claims, approximately 6% of all EPs would earn an upward quality tiering adjustment, 83% would earn a neutral adjustment and 11% would earn a downward quality tiering adjustment.

19 CMS did announce they are considering including or allowing groups that have hospital-based physicians to elect the inclusion of the hospital Value-Based Purchasing (VBP) program performance in the VBM calculation in future years of the program. This may better align incentives for quality improvement and cost control across CMS programs according to CMS. They would also then have to assess and analyze under what methodology to determine which hospital or hospitals performance would apply to any given TIN. They discuss three (3) options for including Hospital VBP program performance in the VBM and seek provider input. Reports of Payments or Other Transfers of Value to Covered Recipients (Open Payments Sunshine Act) The Affordable Care Act held a provision (now commonly known as the Sunshine Act) that mandated the creation of a program that would require (1) reporting payments and other transfers of value made to covered recipients and physician owners or investors, by manufacturers of drugs, devices, biologicals, or medical supplies for which payment is available under Medicare, Medicaid, or the Children's Health Insurance Program (CHIP); and (2) reporting ownership or investment interests held by physicians or their immediate family members in applicable manufacturers and applicable Group Purchasing Organizations (GPOs), as well as reporting payments or transfers of value made by these applicable manufacturers and applicable GPOs to these physicians. The Open Payments program was developed in response to the Sunshine Act, and according to CMS promotes transparency by publishing data on the financial relationships between the healthcare industry (applicable manufacturers and applicable GPOs; together referred to as reporting entities) and healthcare providers (physicians and teaching hospitals) on a website that can be accessed by the public for evaluation and inspection. Essentially it requires drug and device companies to disclose payments to physicians. The applicable vendors and manufactures have reported their 2013 data and physicians have an opportunity to review and dispute the data that has been reported; they can register in CMS s Enterprise portal and review and potentially dispute the data prior to being released to the public on September 30 of The review period is in progress; it runs from July 14, 2014 through August 27th, Physicians are encouraged to review the data and register as soon as possible to ensure adequate dispute time if necessary. Physicians can access the link below to access registration instructions, and once registered can review the reported data and they will have a variety of options available to either; affirm their payment, dispute it with an explanation, or withdraw a dispute. cy-program/program-registration.html Through the 2015 rule, CMS proposes some changes to the Open Payments Program as: removing the exclusion for payments to physicians for speaking at certain accredited continuing education programs; requiring manufacturers to report the marketed name of all products; associated with reported payments or transfers of value (if any); separating out form descriptors used in reporting ownership interests and removing the definition of covered device. Missy Lovell, BSN, RN, MBA is compliance manager at Zotec Partners. Lonnie Johnson, MBA is partner, corporate services at Zotec Partners.

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