hot topics in reimbursement q2 2019 - community …...4/3/19 confidential –do not distribute 1 hot...

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Confidential– Donotdistribute

HotTopicsInReimbursementQ22019

BobbiBuellMBA800-795-2633

[email protected]@yahoo.com

NEWSLETTER:www.onpointoncology.com


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Disclaimer

• Theinformationdescribedhereinissubjecttochangeasmanyofthedetailshereinaresubjecttointerpretation.

• CPTcodesanddescriptionsonlyarecopyright2019AmericanMedicalAssociation(AMA).Allrightsreserved.TheAMAassumesnoliabilityfordatacontainedornotcontainedherein.

• AllMedicareinformationisderivedfrompublishedrules;however,interpretationsmaybeerroneousandtyposmaybeevidenced.Itismandatorythatcodingandbillingisbasedoninformationderivedfromeachpracticeorclinic.

• Thisisnotlegalorpaymentadvice.• ThiscontentisabbreviatedforMedicalOncology.Itdoesnotsubstituteforathoroughreviewofcodebooks,regulations,andCarrierguidance.

• Thisinformationisvalidforthedateofpresentationonly.• Thispresentationshouldnotbereproducedwithoutthepermissionoftheauthorandistimesensitive


33

AGENDA

• FINALPhysicianFeeScheduleRulefor2019• FINALHospitalOutpatientPaymentProgramRule2019• CPT/HCPCSCodes• PartC/PartDchanges• HCC(RiskAdjustment)Coding• Appendices


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FINALPhysicianFeeSchedulefor2019


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WebSitesfor2019FINALRegulations

• Thispresentationisbasedonpublishedrules• PHYSICIANS:https://www.cms.govwww.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/• HOPPS:https:///Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices.html


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MedicarePhysicianPaymentBasics

• PaymentsarebasedonRVUsforeachcode(WRVUs+PERVUs+MalRVUs)• RVUsaremultipliedtimesGPCIsforyourgeographicallocation(W*WGPCI+PE*PEGPCI+Mal*MalGPCI)• TheMedicareconversionfactordeterminestheoveralllevelofMedicarepayments(W*WGPCI+PE*PEGPCI+Mal*MalGPCI)timesCF=$YourTotalAllowableforyourarea,whichwillbeinflated,deflated,orneutralizedbyyourQPPperformance.

W=Work;PE=PracticeExpense;MAL=ExpenseofMalpractice;RVUs=relativevalueunits


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CONVERSIONFACTORProposedfor2019

Source:PHYSICIANFINALFeeScheduleFINALRule2019,Table92


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FeeSchedule:DoesNotIncludeSequestration• Sequestration:

• Medicare2%acrosstheboardstartedonApril1,2013• Impactseverythingincludingdrugs• The2%comesoutoftheMedicareportion(80%)

• Drugsarepaidat104.304%ASP• Allpatientpaymentsexcluded

• Murray-RyanBudgetDealextendedtheSequesteruntil2023;PAMAextendeditto2024,andlastyear’sbudgetdealextendsitto2025.

Formoreaboutsequestration:https://www.nejm.org/doi/full/10.1056/NEJMp1303266?query=TOC&goback=.gde_917937_member_224781137&page=-33&sort=oldest


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ImpactOnHem-Onc:FINALRule

2018

Table94:FINALFeeSchedule


1010

PartBDrugChanges2019--

FINALIZED

• CMSbelievesthatdrugsarepaidtoohighlyatlaunch.

• StartingJanuary1,willpareWACplus6%toWAC3%fortheperiodbeforethedevelopmentofAverageSalesPrice.

• Questionforproviders—whatpercentageofyournewdrugsarepaidusinginvoicesversusarepaidonWACduringthelaunchperiod?

Formoreinformation,seepage667,DisplayCopy.2019FinalRule


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AppropriateUseCriteriaforAdvancedImaging

• Inthe2019proposedrule,CMSreaffirmedtheJanuary1,2020mandatoryconsultationdate,withaone-yeareducationandoperationstestingperiod.Thishasbeenintheregulationsfor5years.

• Inordertomeetthisdeadline,CMSrecommendsuseofaseriesofG-codesandmodifierforclaimsprocessing.Theagencynotesthatitwillconsiderfutureopportunitiestouseauniqueconsultationidentifier(UCI)forclaimsprocessingandwillcontinuetoengagewithstakeholdersonthistopic.

• CMSaddedindependentdiagnostictestingfacilities(IDTFs)tothedefinitionof"applicablesetting"fortheAUCprogram.Otherapplicablesettingsincludeaphysician'soffice,ahospitaloutpatientdepartment(includinganemergencydepartment)andanambulatorysurgicalcenter.


1212

RadiologyAssistants

• “AfterconsiderationofthesecommentsontheRFI,aswellasinformationprovidedbystakeholders,weproposedtoreviseourregulationstospecifythatalldiagnosticimagingtestsmaybefurnishedunderthedirectsupervisionofaphysicianwhenperformedbyanRAinaccordancewithstatelawandstatescopeofpracticerules.• StakeholdersrepresentingtheradiologycommunityhaveprovideduswithinformationshowingthattheRAdesignationincludesregisteredradiologistassistants(RRAs)whoarecertifiedbyTheAmericanRegistryofRadiologicTechnologists,andradiologypractitionerassistants(RPAs)whoarecertifiedbytheCertificationBoardforRadiologyPractitionerAssistants.• Weproposedtoreviseourregulationat¤410.32toaddanewparagraph(b)(4)tostatethatdiagnostictestsperformedbyanRRAoranRPArequireonlyadirectlevelofphysiciansupervision,whenpermittedbystatelawandstatescopeofpracticeregulations.“

FinalRule,DisplayCopy,page186


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E/MChanges2019:ChoosingtheAppropriateCode andProvidingSupporting Documentation

• ForcodingandbillingthePFS,practitionersmayuseeitherthe1995or1997E/Mdocumentationguidelines.TheseareverysimilartoaparallelsetofguidelinespresentintheCPTcodebook.

• Theseguidelinesspecifymedicalrecordinformationwithineachofthe threecomponentsthatservesassupportforbillingagivenvisit level—thehistory,physical,andmedicaldecision-making

CPTcodes,descriptionsandotherdataonlyarecopyright2017AmericanMedicalAssociation.Allrightsreserved.CPTisaregisteredtrademarkoftheAmericanMedicalAssociation (AMA). 6


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E/M2019:Why Change?• StakeholdershavesaidthattheE/Mdocumentationguidelines,andthecode

setitselfareclinicallyoutdatedandmaynotreflectthemostclinicallymeaningful orappropriatedifferencesinpatientcomplexityandcare.Furthermore,theguidelinesmaynotbereflectiveofchangesintechnology,orinparticular,thewaythatelectronicmedicalrecordshavechangeddocumentationandthepatient'smedical record.

• Accordingtostakeholders,someaspectsofrequireddocumentationareredundant

• WithEMRs,thereistoomuchcuttingandpastingtomeetrequirements.

• Additionally,currentdocumentationrequirementsmaynotaccountforchangesincaredelivery,suchasagrowingemphasisonteam-basedcare,increasesinthenumberofrecognizedchronicconditions,orincreasedemphasisonaccesstobehavioralhealth care.


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Final Policies for E/M Visits Starting in2019For2019andbeyond,CMSfinalizedthefollowingoptionalbutbroadly supporteddocumentationchangesforE/Mvisits,thatdonotrequirechangesincoding/payment.• Eliminationoftherequirementtodocumentthemedicalnecessityofahome

visitinlieuofanoffice visit;• Forhistoryandexamforestablishedpatientoffice/outpatientvisits,when

relevantinformationisalreadycontainedinthemedicalrecord,• practitionersmaychoosetofocustheirdocumentationonwhathas

changedsincethelastvisit,oronpertinentitemsthathavenotchanged,

• andneednotre-recordthedefinedlistofrequiredelementsifthereisevidencethatthepractitionerreviewedthepreviousinformationandupdateditas needed.


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Final Policies for E/M VisitsStarting in 2019• Additionally,weareclarifyingthatforchiefcomplaintandhistoryfornewand

establishedpatientoffice/outpatientvisits,• practitionersneednotre-enterinthemedicalrecordinformationthat

hasalreadybeenenteredbyancillary stafforthebeneficiary.• Thepractitionermaysimplyindicateinthemedicalrecordthatheorshe

reviewedandverifiedthis information.


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E/M2019:TeachingPhysicians

• Asageneralrule,Medicareregulationshistoricallyhaverequiredteachingphysiciansto• (1)bepresentatthetimeaserviceisfurnished,and• (2)personallydocumenttheirparticipationintheprovisionofE/Mservices.42C.F.R.§ 415.172(b)(2018).• Anexceptionforlow- andmid-levelcomplexityE/Mservicesfurnishedinoutpatientdepartmentsofteachinghospitals(orotherambulatorycaresettingsforwhichteachinghospitalsareeligibletoreceiveGMEreimbursement)permitsexperiencedmedicalresidentstoperformcertainE/Mservicesoutsidethedirectpresenceoftheteachingphysician,butalsohasrequired—untilnow—theteachingphysiciansthemselvesto"documenttheextentof[hisorher]participationinthereviewanddirectionoftheservices."42C.F.R.§ 415.174(a)(3)(v)(2018).


1818

E/M2019:TeachingPhysicians

• IntheCY2019MPFSFinalRule,CMShasremovedtherequirementthatdocumentationoftheteachingphysician'sparticipationintheE/Mservicetobeenteredpersonallybytheteachingphysician.Medicareregulationsarerevised,effectiveJanuary1,2019,toprovideexpresslythatwhilesuchdocumentationstillisrequired,the"extentoftheteachingphysician'sparticipation[inanE/Mservicefurnishedbyaresidentintheoutpatientdepartmentofateachinghospital]maybedemonstratedbythenotesinthemedicalrecordsmadebyaphysician,resident,ornurse."42C.F.R.§ 415.174(a)(6)(2019).• Theseregulatorychangesareconsistentwith,andbuildupon,revisionsearlierthisyeartotheMedicareClaimsProcessingManual,whereinCMSreviseddocumentationrulesto permitteachingphysicianstoverify,ratherthanhavingtore-document,medicalrecordnotationsenteredbymedicalstudents whoassistintheperformanceofabillableE/Mservice.• Again,thisisforlowtomoderatecomplexityservices.


1919

AdvancingVirtual Care• In response to the CY 2018 PFS Proposed Rule, CMS received feedback fromstakeholders supportive of CMS expanding access to services that utilizetechnological developments in healthcare.

• CMSis interestedinrecognizingchangesinhealthcarepracticethatincorporateinnovationandtechnologyinmanagingpatient care.

• CMS aims toincreaseaccessforMedicarebeneficiariestotheseservicesthatareroutinelyfurnishedviacommunicationtechnologybyclearlyrecognizingadiscretesetofservicesthataredefinedbyandinherentlyinvolvetheuseofcommunication technology.


2020

AdvancingVirtualCare(cont.)

Tosupportaccesstocareusingcommunicationtechnology,weare finalizingpolicies to:

• Paycliniciansforvirtualcheck-ins– brief,non-face-to-faceassessmentsviacommunication technology.

• Paycliniciansforremoteevaluationofpatient-submittedphotos orrecorded video.

• PayRuralHealthClinics(RHCs)andFederallyQualifiedHealthCenters(FQHCs)forthesekindsofservices- outsideoftheRHCall-inclusiverateandtheFQHCProspectivePaymentSystem rate.


2121

Technology-BasedServicesfor2019

• BriefCommunicationTechnology-BasedService,calleda"VirtualCheck-In"(HCPCScodeG2012),wouldbebillablewhenaphysicianorotherqualifiedhealthcareprofessional("QHCP")hasabriefnon-face-to-facecheck-inwithapatientviacommunicationtechnology,todeterminewhetherthepatient'sconditionnecessitatesanofficevisit.Theservicewouldhavea0.25workrelativevalueunit(RVU)andbedescribedwithaG-code,G2012(Briefcommunicationtechnology-basedservice,e.g.virtualcheck-in,byaphysicianorotherqualifiedhealthcareprofessional whocanreportevaluationandmanagementservices,providedtoanestablishedpatient,notoriginatingfromarelatedE/Mserviceprovidedwithintheprevious7daysnorleadingtoanE/Mserviceorprocedurewithinthenext24hoursorsoonestavailableappointment;5-10minutesofmedicaldiscussion).• Evaluationofpre-recordedinformation:ThesecondproposednewserviceisRemoteEvaluationofPre-RecordedPatientInformation(HCPCSCodeG2010),whichwouldallowpractitionerstobepaidseparatelyforreviewingpatient-transmittedphotoorvideoinformationtoassesswhetheravisitisneeded. Page66,DisplayCopy,ProposedRuleandPage108,DisplayCopy,FinalRule


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Technology-BasedServicesMedicarewillpayfortheseservicesin2019BUTREADTHECPTDESCRIPTORS!!• CPT99446:Inter-professionaltelephone/Internetassessmentandmanagementserviceprovidedbyaconsultativephysicianincludinga verbalandwrittenreporttothepatient'streating/requestingphysicianorotherqualifiedhealthcareprofessional;5-10minutes ofmedicalconsultativediscussionandreview

• CPT99447:Sameas99446,but11-20minutes ofmedicalconsultativediscussionandreview

• CPT99448:Sameas99446,but21-30minutes ofmedicalconsultativediscussionandreview

• CPT99449:Sameas99446,but31minutesormore ofmedicalconsultativediscussionandreview

• CPT99451:Inter-professionaltelephone/Internet/electronichealthrecordassessmentandmanagementserviceprovidedbyaconsultativephysicianincludingawrittenreporttothepatient’streating/requestingphysicianorotherqualifiedhealthcareprofessional,5ormoreminutes ofmedicalconsultativetime

• CPT99452:Inter-professionaltelephone/Internet/electronichealthrecordreferralservice(s)providedbyatreating/requestingphysicianorqualifiedhealthcareprofessional,30minutes

• Patientmustconsenttocost


2323

TelehealthServices—Additionsfor2019--FINAL

• CMSwilladdmobilestrokeunits,renaldialysisfacilitiesandthehomesofESRDbeneficiariesreceivinghomedialysistothedefinitionof"originatingsite."

• Also,theyadded:telehealthservicesbeginninginCY2019onacategory1basis:• HCPCScodeG0513(Prolongedpreventive

service(s)(beyondthetypicalservicetimeoftheprimaryprocedure),intheofficeorotheroutpatientsettingrequiringdirectpatientcontactbeyondtheusualservice;first30minutes(listseparatelyinadditiontocodeforpreventiveservice)and

• HCPCScodeG0514:(Prolongedpreventiveservice(s)(beyondthetypicalservicetimeoftheprimaryprocedure),intheofficeorotheroutpatientsettingrequiringdirectpatientcontactbeyondtheusualservice;eachadditional30minutes(listseparatelyinadditiontocodeG0513foradditional30minutesofpreventiveservice).

StartsonPage63,DisplayCopy,ProposedRule


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Evaluation&ManagementServices:CompleteOverhaulProposal=2021• Overview

• Thisproposal,whichwasdelayeduntil2021,appliesONLYtoofficevisits—NewandEstablished

• Visitsnowarebasedoncriteriaestablishedin1995and1997—history,physical,medicaldecision-making,etc.

• Proposalfor2021• Visitscanbecodedbasedononeofthreedeterminants

• Currentcriteriafor99212orallcodes• Timeforthecode• MedicalDecision-making

• Add-onsfor• PrimaryCare• Specialists• ProlongedServices(differentfromCPT)

Startsonpage537,DisplayCopy,FINALRule


2525

PoliciesforE/MOffice/OutpatientVisitsStartingin 2021

• BeginninginCY2021,CMSwillimplementpayment,coding,andadditionaldocumentationchangesforE/Moffice/outpatientvisits, specifically:o Singleratesforlevels2through4forestablishedandnewpatients,

maintainingthepaymentratesforE/Moffice/outpatientvisitlevel5inordertobetteraccountforthecareandneedsofcomplex patients;

o Add-oncodesforlevel2through4visitsthatdescribetheadditionalresourcesinherentinvisitsforprimarycareandparticularkindsofnon-proceduralspecializedmedical care;


2626

SpecialtyAdditionalPayments(2021)

• Visitcomplexityinherenttoevaluationandmanagementassociatedwithnonproceduralspecialtycareincludingendocrinology,rheumatology,hematology/oncology,urology,neurology,obstetrics/gynecology,allergy/immunology,otolaryngology,interventionalpainmanagement,cardiology,nephrology,infectiousdisease,psychiatry,andpulmonology.(Add-oncode,listseparatelyinadditiontolevel2through4office/outpatientevaluationandmanagementvisit,neworestablished)

Page370,DisplayCopy,ProposedRule


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PrimaryCarePayments(2021)

• AG-codewillbeestablishedthatcanbebilledwithanyprimarycareestablishedpatientE&MvisittoaddadditionalRVUstothepaymenttoaccountfortheadditionalresourcesofthecognitiveworkofprimarycarephysiciansORofspecialistsworkingasthepatient'sprimarycarephysicianatthattime.Visitcomplexityinherenttoevaluationandmanagementassociatedwithprimarymedicalcareservicesthatserveasthecontinuingfocalpointforallneededhealthcareservices(Add-oncode,listseparatelyinadditiontolevel2through4office/outpatientevaluationandmanagementvisit,neworestablished)

This image cannot currently be displayed.


2828

AdditionalE/MAdjustments

• CMSisfinalizingacodingandpaymentpolicytoaccountfortheadditionalresourcesrequiredwhenpractitionersneedtospendextendedtimewiththeirpatientsduringaparticularE/Moffice/outpatientlevel2through4visits,regardlessofthekindofcarethepractitionerisfurnishingorwhetherornotthemedicalcomplexityofthevisitisthedeterminingfactorforthelengthofvisit.ThereisanexpectationthatSpecialistswithhighnumbersofLevel4sand5swillusethiscode.(Page614,DisplayCopy,FinalRule)• “ForCY2021,CMSbelievesthat30additionalminutes(which,inaccordancewithCPTcodingconventionsfortimedcodes,canbereportedafter15additionalminutesisspentwiththepatient)isanappropriateintervaloftimeafterwhichtoreflecttheadditionalresourcecostsassociatedwithpatientvisitsthatrequiremoretimethanistypicalforthevisit.”Thiswillbepaidatapproximately50%ofa99354.Page619,DisplayCopy,FinalRule


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PoliciesforE/MOffice/OutpatientVisitsStartingin2021(cont.)o Anew“extendedvisit”add-oncodeforlevel2through4visitstoaccountfortheadditionalresourcesrequiredwhenpractitionersneedtospendadditionaltimewith patients.

o Forlevel2through5visits,choicetodocumentusingthecurrentframework,MDMor time;▪ Whentimeisusedtodocument,practitionerswilldocumentthemedicalnecessityofthevisitandthatthebillingpractitionerpersonallyspenttherequiredamountoftimeface-to-facewiththebeneficiary(typicalCPTtimeforcodereported,plusanyextended/prolonged time).

▪ WhenusingcurrentframeworkorMDMtodocument,forlevel2through4visitsCMSwillonlyrequirethesupportingdocumentationcurrently associatedwithLevel2visits.


30

PaymentRates

FromDisplayCopy,FinalRule,Page624


3131

DocumentingUsing Time

31

Code(s) Required Time(minutes)

Estimated Payment

99212 10 $90

99213 15 $90

99214 25 $90

99215 40 $148


3232

DocumentingUsingTime (cont.)

32

Code(s) Required Time(minutes)

Estimated Payment

99212extended(99212+ GPRO1) 34-69 $157

99213 extended(99213+GPRO1) 34-69 $157

99214 extended(99214+GPRO1) 34-69 $157

99215 prolonged(99215+ 99354-5) 70+ $281+


33

EstimatedPaymentBeginning2021forOffice/OutpatientE/MVisits

*CurrentPaymentforCY 2018**EstimatedPaymentbasedontheCY2019finalizedrelativevalueunitsandtheCY2018payment rate 33

Level Current

Payment*

(established

patient)

EstimatedPaymentbeginning2021**

1 $22 $242 $45 $90($103for primary

careandnon-proceduralcare)

3 $744 $109

5 $148 $148


34

RealMedicalOncologyNumbersProjections2019versus2021

E/MVolume=focalPoint®2018PaidMedicareClaims

Code Payer

Paid Claim Count With No -25 Price 2019 Price 2021

Price 2021 w/add-on Total 2019

Total 2021 Without Add-on Total 2021 With Add on

99201 Medicare 71 $46 $46 $46 3,300.79$ 3,300.79$ 3,300.79$ 99202 Medicare 931 $77 $130 $143 72,133.88$ 121,030.00$ 133,133.00$ 99203 Medicare 9,604 $110 $130 $143 1,055,671.68$ 1,248,520.00$ 1,373,372.00$ 99204 Medicare 38,964 $167 $130 $143 6,501,533.04$ 5,065,320.00$ 5,571,852.00$ 99205 Medicare 52,526 $210 $210 $210 11,017,328.50$ 11,017,328.50$ 11,017,328.50$ TOTAL 18,649,967.89$ 17,455,499.29$ 18,098,986.29$ 99211 Medicare 45,223 $23 $24 $24 1,043,294.61$ 1,085,352.00$ 1,085,352.00$ 99212 Medicare 23,438 $46 $90 $103 1,072,757.26$ 2,109,420.00$ 2,414,114.00$ 99213 Medicare 445,227 $75 $90 $103 33,534,497.64$ 40,070,430.00$ 45,858,381.00$ 99214 Medicare 761,767 $110 $90 $103 84,007,664.76$ 68,559,030.00$ 78,462,001.00$ 99215 Medicare 105,952 $148 $148 $148 15,655,467.52$ 15,655,467.52$ 15,655,467.52$ TOTAL 135,313,681.79$ 127,479,699.52$ 143,475,315.52$

Total All Codes 153,963,649.68$ 144,935,198.81$ 161,574,301.81$


35

AreYouMissingReimbursement?


3636

CareCoordinationintheOCM

Notethatnon-OCMpractitionersmaybillfortheseservicesforOCMbeneficiariesduringmonthsthatOCMpractitionersbilltheMEOS.TheMEOScannotbebilledafterbeneficiarieshavediedorenteredhospice

OCMpractitionerscannotbillforthefollowingcarecoordinationservicepaymentsforOCMbeneficiariesforthemonthsthattheybilltheMEOS:•

ChronicCareManagement(CCM)•

TransitionalCareManagement(TCM)•HomeHealthCare

Supervision

HospiceCareSupervision EndStageRenalDisease(ESRD)


3737

InvestigatingAdditionalE/MServices

• Noticeforeachoftheseservicesthefollowing:• Reimbursementversusextrawork• Periodrequirements• Encountertimeframe• FollowUptimeframe• FTFversusVirtual• Whocanperform:MD/DO,NPP,Staff• Consent• CCIedits

• Traintothedocumentationrequirementsabove• InstallEMRtemplates


3838

ForFurther Information

27

SeethePhysicianFeeSchedulewebsite at:https://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/PhysicianFeeSched/index.html

SeetheMIPswebsiteat:https://qpp.cms.gov


39

FinalRuleHospitalOutpatientPayment2019


4040

Statusof340BMedicarePricing

• Non-pass-throughdrugspurchasedunder340BpricingarepricedatASPMINUS22.5%.• However,inlateDecember,aconsortiumofhospitalgroupssuedCMSstatingthatCMShad‘oversteppeditsauthority’.• Thislawsuitisstillwendingitswaythroughthecourts.But,thebottomlineisthatASPminus22.5%maynotstandfor2019.


4141

2019HOPPSDrugPayments

Atlaunch,drugsandbiologicalproductsthatdonothavepass-throughpaymentstatusatwholesaleacquisitioncost(WAC)+3percentinsteadofWAC+6percent.IfWACdataarenotavailableforadrugorbiologicalproduct,weareproposingtocontinueourpolicytopayseparatelypayabledrugsandbiologicalproductsat95percentoftheaveragewholesaleprice(AWP).

Alldrugswhosecostis$125orlessperencounter,accordingtoCMS,willbebundledintotheAPC.Thisa$5increasefromlastyear—lessthantheusual$10increase

Paynon-pass-throughbiosimilarsacquiredunderthe340BprogramatASPminus22.5percentofthebiosimilar’sownASPratherthanASPminus22.5percentofthereferenceproduct’sASP(maybe—lawsuit).

DisplayCopyProposedHospitalOutpatientRule,page274;FinalRule,DisplayCopy,page23


4242

FacilityFees:Controlof“UnnecessaryServices”

• ThispolicywouldresultinlowercopaymentsforbeneficiariesandsavingsfortheMedicareprograminanestimatedamountof$380millionfor2019,• Firstyearofatwoyearphase-in(2019)• ForanindividualMedicarebeneficiary,currentMedicarepaymentfortheclinicvisitfurnishedinanexceptedoff-campusPBDisapproximately$116with$23beingtheaveragebeneficiarycopayment.

• ThepolicytoadjustthispaymenttothePFSequivalentratewouldreducetheOPPSpaymentratefortheclinicvisitto$81withabeneficiarycopaymentof$16(basedonatwoyearphase-in),thussavingbeneficiariesanaverageof$7eachtimetheyvisitanoff-campusdepartmentinCY2019

https://www.cms.gov/newsroom/fact-sheets/cms-finalizes-medicare-hospital-outpatient-prospective-payment-system-and-ambulatory-surgical-center


4343

Section603:Paymentfor2018-2019

Theseentitieswillstillbepaidat40%of

theHOPPSrate

•Thisdoesnotincludedrugsorlabs


4444

Section603:Non-ExceptedFacilities

• BeginningJanuary1,2018,MedicarepaysanadjustedamountoftheASPminus22.5%forcertainseparatelypayabledrugsorbiologicalsthatareacquiredthroughthe340BProgrambyahospitalpaidundertheOPPSthatisnotexceptfromthepaymentadjustmentpolicy.ForCY2018,ruralsolecommunityhospitals(SCHs),children’shospitals,andPPS-exemptcancerhospitalsareexceptedfromthe340Bpaymentadjustment.• IntheCY2018OPPS/ASCfinalrulewithcommentperiod,afewcommentersraisedthatthe340Breductionwouldnotapplytonon-exceptedoff-campusPBDsandsharedtheirviewthatthiscouldresultinbehavioralchangesthatmayundermineCMS’policygoalsofreducingbeneficiarycost-sharingliability.Thisyear,CMSwastoadoptapolicytopayASPminus22.5%for340B-acquireddrugsfurnishedbynon-exceptedoff-campusprovider-baseddepartments.340Bdrugpaymentiscurrentlythesubjectofalawsuitandwillchange.

DisplayCopy,ProposedHospitalOutpatientRule,page387


4545

CancerHospitalAdjustments

• CancerHospitalPaymentAdjustment:ForCY2019,CMSwillcontinuetoprovideadditionalpaymentstocancerhospitalssothatthecancerhospital’spayment-to-costratio(PCR)aftertheadditionalpaymentsisequaltotheweightedaveragePCRfortheotherOPPShospitalsusingthemostrecentlysubmittedorsettledcostreportdata.However,section16002(b)ofthe21stCenturyCuresActrequiresthatthisweightedaveragePCRbereducedby1.0percentagepoint.Basedonthedataandtherequired1.0percentagepointreduction,weareproposingthatatargetPCRof0.88wouldbeusedtodeterminetheCY2019cancerhospitalpaymentadjustmenttobepaidatcostreportsettlement.Thatis,thepaymentadjustmentswouldbetheadditionalpaymentsneededtoresultinaPCRequalto0.88foreachcancerhospital.

DisplayCopy,ProposedHospitalOutpatientRule,page2andDisplayCopy,FinalRule,page24


4646

PriceTransparency2019

• CMSsayssupplierscanandshouldberequiredtoinformpatientsaboutchargesandpaymentinformationforhealthcareservicesandout-of-pocketcosts,whatdataelementsthepublicwouldfindmostuseful,andwhatotherchangesareneededtoempowerpatients.• Somehospitalshavereleasedtheirfeeschedulesand/orChargemasters

DisplayCopy,ProposedHospitalOutpatientRule,page638


4747

PaymentUpdatefor

APCs

• CMShistoricallyupdatedASC(AmbulatorySurgeryCenters)paymentratesannuallybythepercentageincreaseintheConsumerPriceIndexforallurbanconsumers(CPI-U).IntheCY2018OPPS/ASCproposedrule,CMSsolicitedrecommendationsandideasonASCpaymentsystemreform.FortheCY2019OPPS/ASCproposedrule,inresponsetothecommentsreceived,CMSproposedtoupdateASCpaymentratesusingthehospitalmarketbasketratherthantheCPI-UforCY2019throughCY2023.WealsosoughtcommentonanalternativeproposaltomaintainCPI-Uwhilecollectingevidencetojustifyadifferentpaymentupdate,oradoptingthenewproposedpaymentupdatebasedonthehospitalmarketbasketpermanently.

• Wearefinalizingthisproposalwithoutmodification.Usingthehospitalmarketbasket,CMSisupdatingASCratesforCY2019by2.1percent.Thechangeisbasedonthehospitalmarketbasketincreaseof2.9percentminusa0.8percentagepointadjustmentforMFP. Thischangewillhelptopromote“site-neutrality”betweenhospitalsandASCsandencouragethemigrationofservicesfromthehospitalsettingtothelowercostASCsetting.

CMSOutpatientFactSheethttps://www.cms.gov/newsroom/fact-sheets/cms-finalizes-medicare-hospital-outpatient-prospective-payment-system-and-ambulatory-surgical-center


4848

HospitalQualityProgram• CMSisnotfinalizingremovaloftwoofthetenmeasuresproposedforremoval.IntheCY2019OPPS/ASCfinalrule,CMSisfinalizingpoliciesto:• UpdatetheCodeofFederalRegulationstoretainmeasuresfromapreviousyear’sHospitalOQRProgrammeasuresetfor

subsequentyears’measuresets.• UpdatetheCodeofFederalRegulationstousetheregularrulemakingprocesstoremoveameasureforcircumstancesthat

donotraisespecificpatientsafetyconcerns.• UpdatetheCodeofFederalRegulationstoimmediatelyremovemeasuresasaresultofpatientsafetyconcerns.• RemoveonequalitymeasurebeginningwiththeCY2020paymentdeterminationandsevenqualitymeasuresbeginning

withtheCY2021paymentdetermination.WenotethatwearenotfinalizingourproposalstoremovetheAppropriateFollow-UpIntervalforNormalColonoscopyinAverageRiskPatients(OP-29)andtheCataracts:ImprovementinPatient’sVisualFunctionwithin90DaysFollowingCataractSurgery(OP-31)measures.

• ExtendthereportingperiodfromonetothreeyearsforOP-32: FacilitySeven-DayRisk-StandardizedHospitalVisitRateafterOutpatientColonoscopybeginningwiththeCY2020paymentdeterminationandforsubsequentyears.

• UpdatetheCodeofFederalRegulationsthefactorstobeconsideredwhenremovingmeasuresfromtheprogramandcodifymeasureremovalpolicies.

• ChangethefrequencyoftheHospitalOQRProgramSpecificationsManualreleasebeginningwithCY2019andforsubsequentyearssuchthattheywillbereleasedonceeverytwelvemonthswithaddendaasnecessary– amodificationfromwhatwasproposed.

• Updaterequirementsrelatedtoparticipationstatus,includingremovaloftheNoticeofParticipationformforthefortheCY2020paymentdetermination

CMSFactSheet:FinalRuleHospitalOutpatientProspectivePayment2019


49

MedicareHOPPSPaymentVersusOfficePaymentforDrugAdministration(NationalRates)

Code Brief Description PFS2018 PFS2019

APC2018 APC2019

96361 Hydrationover30minutes,separate

$14.04 $13.69 $37.03 $37.88

96367 Therapeutic infusion,separate&seq

$32.04 $31.71 $58.20 $59.75

96372 Therapeuticinjection $20.88 16.72 $58.20(Q1)

$59.75(Q1)

96413 Chemotherapy,initialinfusion $144.72 $143.08 $297.54 $288.38

96417 Chemotherapy infusion,separate&sequential

$69.48 $69.20 $58.20 $59.75


50

CPT/HCPCSCodeChangesDatesofService1/1/2019andThereafter


5151

EvaluationandManagement– ChangesOverview• Therearesixnew codesintheEvaluationandManagement(E&M)sectioninCPT.• GuidelineswererevisedforInter-professionalTelephone/Internet/ElectronicHealthRecordConsultationstoensurethatnewcodesarefacilitated.


5252EvaluationandManagement99451and99452– ElectronicRecordAssessment/Consultative

Services• Inter-professionaltelephone/Internet/electronichealthrecordassessmentandmanagementserviceprovidedbyaconsultativephysician,includingawrittenreporttothepatient’streating/requestingphysicianorotherqualifiedhealthcareprofessional,5minutesormoreofmedicalconsultativetime.• Consultativeservicelastingmorethan5minutesandrequiresonlyawrittenreporttotherequestingphysician.

• Thiswasaddedrecognizingthatoralcommunicationsdonotalwaysoccurbetweenhealthcareprofessionalsandmayfacilitateconsultativeservicesingeographicareaswithnospecialistsavailable.


5353EvaluationandManagement99453and99454– RemotePhysiologicMonitoringServices

• 99453 – Remotemonitoringofphysiologicalparameter(s)(e.g.,weight,bloodpressure,pulseoximetryrespiratoryflowrate,initial;setup,patienteducationonuseofequipment• 99454 - Remotemonitoringofphysiologicalparameter(s)(e.g.,weight,bloodpressure,pulseoximetryrespiratoryflowrate,initial;device(s)supply,withdailyrecording(s)orprogrammedalert(s)transmission,each30days.


5454

EvaluationandManagement99457– RemotePhysiologicMonitoringServices

• 99457 - Remotephysiologicmonitoringtreatmentmanagementservices,20minutesormoreofclinicalstaff/physician/otherqualifiedhealthcareprofessionaltimeinacalendarmonthrequiringinteractivecommunicationwiththepatient/caregiverduringthemonth


555599491– ChronicCareManagement(PersonallyPerformedbyProvider)

•WhenServicesarepersonallyperformedbyaphysicianorotherqualifiedhealthcareprofessional,atleast30minutesofphysicianorotherqualifiedhealthcareprofessionaltime,percalendarmonth.•Majordifferencebetweenthisandthe99490 CCMservicescodeiswhentheproviderpersonallyperformsthedifferenceintimewouldbe30minutes.Comparedto20minutesforclinicalstaff


5656

CentralLines

• Centralvenousaccessrevisions– Thechangestotheperipherallyinsertedcentralcatheter(PICC)codesarethestarsofthissection,butdon’toverlookguidanceunderthecentralvenousaccessproceduressubsection.TheCPT2019nowstatesthatitisappropriatetocodeaPICClinewhenasaphenousveinistheinsertionsite.


5757

CentralLines

• Therearealsomoredetailedguidelinesforreportingfluoroscopiccentralvenouscathetercode77001 and76937• 36584- reviseddescription nowincludesimageguidancenew(Replacement,complete,ofaperipherallyinsertedcentralvenouscatheter[PICC],withoutsubcutaneousportorpump,throughsamevenousaccess,includingallimagingguidance,imagedocumentation,andallassociatedradiologicalsupervisionandinterpretationrequiredtoperformthereplacement)


5858CentralLines

• 36572 - Insertionofperipherallyinsertedcentralvenouscatheter[PICC],withoutsubcutaneousportorpump,includingallimagingguidance,imagedocumentation,andallassociatedradiologicalsupervisionandinterpretationrequiredtoperformtheinsertion;(youngerthan5yearsofage)• 36573 - (…;age5yearsorolder)• 36572-36573arenumericallyoutoforderandarebelow36572inthebook

Note: ChestX-raycodes(71045-71048)orotherimagingservicestodocumentthefinalcathetertippositionarebundledinto36584and36572-36573.However,whentheproviderusesimagingbutdoesnotconfirmthetip’slocation,thepracticeshouldappendmodifier52(Reducedservices)withthecode.


5959

Vaccine

• 90689- Influenzavirusvaccinequadrivalent[IIV4],inactivated,adjuvanted,preservativefree,0.25mLdosage,forintramuscularuse)


60

HCPCSCodeAdditions—Non-Cancer/SupportiveCare

C9462 Injection, delafloxacin, 1 mg Injection, delafloxacinJ0185 Injection, aprepitant, 1 mg Inj., aprepitant, 1 mgJ0517 Injection, benralizumab, 1 mg Inj., benralizumab, 1 mgJ0567 Injection, cerliponase alfa, 1 mg Inj., cerliponase alfa 1 mgJ0584 Injection, burosumab-twza 1 mg Injection, burosumab-twza 1mJ0599 Injection, c-1 esterase inhibitor (human), (haegarda), 10 units Inj., haegarda 10 unitsJ0841 Injection, crotalidae immune f(ab')2 (equine), 120 mg Inj crotalidae im f(ab')2 eqJ1301 Injection, edaravone, 1 mg Injection, edaravone, 1 mgJ1454 Injection, fosnetupitant 235 mg and palonosetron 0.25 mg Inj fosnetupitant, palonosetJ1628 Injection, guselkumab, 1 mg Inj., guselkumab, 1 mgJ1746 Injection, ibalizumab-uiyk, 10 mg Inj., ibalizumab-uiyk, 10 mgJ2062 Loxapine for inhalation, 1 mg Loxapine for inhalation 1 mgJ2797 Injection, rolapitant, 0.5 mg Inj., rolapitant, 0.5 mgJ3245 Injection, tildrakizumab, 1 mg Inj., tildrakizumab, 1 mg

J3304Injection, triamcinolone acetonide, preservative-free, extended-release, microsphere formulation, 1 mg Inj triamcinolone ace xr 1mg

J3316 Injection, triptorelin, extended-release, 3.75 mg Inj., triptorelin xr 3.75 mgJ3397 Injection, vestronidase alfa-vjbk, 1 mg Inj., vestronidase alfa-vjbkJ3398 Injection, voretigene neparvovec-rzyl, 1 billion vector genomes Inj luxturna 1 billion vec gJ3591 Unclassified drug or biological used for esrd on dialysis Esrd on dialysi drug/bio nocJ7170 Injection, emicizumab-kxwh, 0.5 mg Inj., emicizumab-kxwh 0.5 mgJ7177 Injection, human fibrinogen concentrate (fibryga), 1 mg Inj., fibryga, 1 mg

J7203Injection factor ix, (antihemophilic factor, recombinant), glycopegylated, (rebinyn), 1 iu Factor ix recomb gly rebinyn

J7318Hyaluronan or derivative, durolane, for intra-articular injection, 1 mg Inj, durolane 1 mg

J7329 Hyaluronan or derivative, trivisc, for intra-articular injection, 1 mg Inj, trivisc 1 mg


61

HCPCSCodeAdditions-Cancer/BiosimilarDrugsJ7329 Hyaluronan or derivative, trivisc, for intra-articular injection, 1 mg Inj, trivisc 1 mgJ9044 Injection, bortezomib, not otherwise specified, 0.1 mg Inj, bortezomib, nos, 0.1 mgJ9057 Injection, copanlisib, 1 mg Inj., copanlisib, 1 mgJ9153 Injection, liposomal, 1 mg daunorubicin and 2.27 mg cytarabine Inj daunorubicin, cytarabineJ9173 Injection, durvalumab, 10 mg Inj., durvalumab, 10 mgJ9229 Injection, inotuzumab ozogamicin, 0.1 mg Inj inotuzumab ozogam 0.1 mgJ9311 Injection, rituximab 10 mg and hyaluronidase Inj rituximab, hyaluronidaseJ9312 Injection, rituximab, 10 mg Inj., rituximab, 10 mgQ5103 Injection, infliximab-dyyb, biosimilar, (inflectra), 10 mg Injection, inflectraQ5104 Injection, infliximab-abda, biosimilar, (renflexis), 10 mg Injection, renflexis

Q5105Injection, epoetin alfa, biosimilar, (retacrit) (for esrd on dialysis), 100 units Inj retacrit esrd on dialysi

Q5106Injection, epoetin alfa, biosimilar, (retacrit) (for non-esrd use), 1000 units Inj retacrit non-esrd use

Q5107 Injection, bevacizumab-awwb, biosimilar, (mvasi), 10 mg Inj mvasi 10 mgQ5108 Injection, pegfilgrastim-jmdb, biosimilar, (fulphila), 0.5 mg Injection, fulphilaQ5109 Injection, infliximab-qbtx, biosimilar, (ixifi), 10 mg Injection, ixifi, 10 mgQ5110 Injection, filgrastim-aafi, biosimilar, (nivestym), 1 microgram NivestymHCPCS/MODCodeAction LongDescriptor ShortDescriptorEffectiveDate

Q5111 ADD Injection,Pegfilgrastim-cbqv,biosimilar,(udenyca),0.5mg. Injection,udenyca0.5mg1/1/19


62

ChangedHCPCSCodesQ9992

Injection, buprenorphine extended-release (sublocade), greater than 100 mg Buprenorphine xr over 100 mg

J0834 Injection, cosyntropin, 0.25 mg Inj., cosyntropin, 0.25 mg

J7178Injection, human fibrinogen concentrate, not otherwise specified, 1 mg Inj human fibrinogen con nos

J8655 Netupitant 300 mg and palonosetron 0.5 mg, oral Oral netupitant, palonosetroJ9041 Injection, bortezomib (velcade), 0.1 mg Inj., velcade 0.1 mgK0037 High mount flip-up footrest, each Hi mount flip-up footrest ea

Q2041

Axicabtagene ciloleucel, up to 200 million autologous anti-cd19 car positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose Axicabtagene ciloleucel car+

Q4133Grafix prime, grafixpl prime, stravix and stravixpl, per square centimeter Grafix stravix prime pl sqcm

Q4137 Amnioexcel, amnioexcel plus or biodexcel, per square centimeter Amnioexcel biodexcel 1sq cm


63

DeletedHCPCSCodesQ4137 Amnioexcel, amnioexcel plus or biodexcel, per square centimeter Amnioexcel biodexcel 1sq cmQ5101 Injection, filgrastim-sndz, biosimilar, (zarxio), 1 microgram Injection, zarxio ZA Novartis/sandoz Novartis/sandoz ZB Pfizer/hospira Pfizer/hospira ZC Merck/samsung bioepis Merck/samsung bioepisC9014 Injection, cerliponase alfa, 1 mg Injection, cerliponase alfaC9015 Injection, c-1 esterase inhibitor (human), haegarda, 10 units C-1 esterase, haegardaC9016 Injection, triptorelin extended release, 3.75 mg Inj, triptorelin ext relC9024 Injection, liposomal, 1 mg daunorubicin and 2.27 mg cytarabine Inj, daunorubicin-cytarabineC9028 Injection, inotuzumab ozogamicin, 0.1 mg Inj. inotuzumab ozogamicinC9029 Injection, guselkumab, 1 mg Injection, guselkumabC9030 Injection, copanlisib, 1 mg Inj copanlisibC9031 Lutetium lu 177, dotatate, therapeutic, 1 mci Lutetium lu 177 dotatate, txC9032 Injection, voretigene neparvovec-rzyl, 1 billion vector genome Voretigene neparvovec-rzylC9033 Injection, fosnetupitant 235 mg and palonosetron 0.25 mg Inj, akynzeo

C9275Injection, hexaminolevulinate hydrochloride, 100 mg, per study dose Hexaminolevulinate hcl

C9463 Injection, aprepitant, 1 mg Injection, aprepitantC9464 Injection, rolapitant, 0.5 mg Injection, rolapitant

C9465Hyaluronan or derivative, durolane, for intra-articular injection, per dose Injection, durolane

C9466 Injection, benralizumab, 1 mg Injection, benralizumabC9467 Injection, rituximab and hyaluronidase, 10 mg Inj rituximab hyaluronidase

C9468Injection, factor ix (antihemophilic factor, recombinant), glycopegylated, rebinyn, 1 i.u. Inj, factor ix, rebinyn

C9469Injection, triamcinolone acetonide, preservative-free, extended-release, microsphere formulation, 1 mg Inj triamcinolone acetonide

C9492 Injection, durvalumab, 10 mg Injection, durvalumabC9493 Injection, edaravone, 1 mg Injection, edaravoneC9497 Loxapine, inhalation powder, 10 mg Loxapine, inhalation powderJ0833 Injection, cosyntropin, not otherwise specified, 0.25 mg Cosyntropin injection nosJ9310 Injection, rituximab, 100 mg Rituximab injection

Q2040

Tisagenlecleucel, up to 250 million car-positive viable t cells, including leukapheresis and dose preparation procedures, per infusion Tisagenlecleucel car-pos t

Q5102 Injection, infliximab, biosimilar, 10 mg Inj., infliximab biosimilar


64

Confidential– Donotdistribute

PartCandD2019-2020


6565

PartC—MedicareAdvantageChangeforThisYear• PerletterfromSeemaVerma,CMSisherebyrescindingourSeptember17,2012HPMSmemo“ProhibitiononImposingMandatoryStepTherapyforAccesstoPartBDrugsandServices,”andissuingnewguidancethatrecognizesMedicareAdvantage(MA)plansmayusesteptherapyforPartBdrugs,beginningJanuary1,2019,aspartofapatient-centeredcarecoordinationprogram.• Finally,MAplanswereinstructedtoensurethatnewsteptherapyrequirementsdonotdisruptongoingPartBdrugtherapiesforenrollees.SteptherapymayonlybeappliedtonewprescriptionsoradministrationsofPartBdrugsforenrolleesthatarenotactivelyreceivingtheaffectedmedication.Also,PartDtransitionrequirementswillcontinuetoapplytoPartDdrugsthataresubjecttosteptherapywherethefirst“step”isaPartBdrug.

https://www.cms.gov/Medicare/Health-Plans/HealthPlansGenInfo/Downloads/MA_Step_Therapy_HPMS_Memo_8_7_2018.pdf


6666

PartC—RiskAdjustmentProposedfor2020• CMSproposestoupdatetheHCCRiskAdjustmentModeltoincludeapaymentvariablerelatedtothenumberofconditionsthatanindividualbeneficiaryisdiagnosedwith.CMSseekscommentsregardingwhichoftwopotentialversionsoftheupdatedmodeltoimplementfor2020payments.• Version1:Currently,theweightofanHCCdominatestheadjustment.Anewriskadjustmentcalledthe"PaymentConditionCount"or"PCC"model,itincludesfactorsthattakeintoaccountthenumberofconditionseachbeneficiaryhas.IntheestablishedCMS-HCCmodel,thepredictedcostforahierarchicalconditioncategory("HCC")isnotimpactedbythepresenceofotherconditionsunlessthatspecificHCCispartofadiseaseinteraction.ThePCCmodelwouldincludeaseparatefactorforthecountofconditions,regardlessofwhatthoseconditionsmaybe,andasthenumberofconditionsincreases,anadjustmentwouldbemadetothetotalpredictedcost(i.e.,theriskscore);

• ORVersion2:ThisversionisexactlythesameasthePCCmodel,butitincludesHCCsforpressureulcersanddementiathatarenotinthecurrentriskadjustmentmodel--notabiggieforcancerclinicsandpractices.

• For2020,CMSproposesphasinginthenewmodelwithablendof50%oftheriskadjustmentmodelfirstusedforpaymentin2017and50%ofthenewmodelmodifiedorchangedfromtheproposal.


6767

PartC—SupplementalBenefitsProposed2020• TheDraftCY2020CallLetterproposestogiveMAplansflexibilitytoprovidecertainenrolleeswithabroaderrangeof

supplementalbenefits.• Traditionally,MAplanshaveonlybeenallowedtooffer"primarilyhealthrelated"supplementalbenefitsandmust

providethemtoallenrollees.• But,beginningin2019,CMSallowedMAplanstooffertargetedsupplementalbenefitsforspecificenrollee

populationsbasedonhealthstatusordiseasestate,aslongasthesupplementalbenefitsareoffereduniformlytothatgroup.YoumayhaveseentheSilverSneakerspushbysomeMedicareAdvantageplans.

• DuetopassageofTheBipartisanBudgetAct,CMSwillallowMAplans,beginningin2020,• tooffernon-primarilyhealthrelatedsupplementalbenefitstochronicallyillenrollees(e.g.,transportationfornon-

medicalneeds,home-deliveredmealsbeyondthecurrentallowablelimitedbasis,food,andproduce).• ThislawalsopermitsCMStowaiveuniformityrequirementsforchronicallyillenrolleesunderthenewprovision,

allowingMAplanstomodifysupplementalbenefitsbasedontheindividualenrollee'sspecificmedicalconditionandneeds.

• WillthisencouragemoreMAparticipation(Nowat36+%)


6868

PartC—Value-BasedInsuranceDesign(VBID)Proposed2020• InadditiontotheAdvanceNoticeandCallLetter,CMSrecentlyissueddocumentationregardinginnovationsthatCMMI(alsoinchargeoftheOncologyCareModel)planstotestthroughtheValue-BasedinsuranceDesign(VBID)modelfor2020.• CMSbeganusingtheVBIDmodelin2017totesttheimpactofprovidingMAplanswiththeabilitytooffer"reducedcostsharing"(MAplanshadthecost-sharingfordrugsin2018,accordingtoourdatabase)oradditionalsupplementalbenefitstoenrolleeswithspecificchronicconditions.

• Untilnow,theVBIDmodelhasonlybeentestedinselectstates.However,beginningin2020,MAplansinall50statesandinU.S.territoriesareeligibletoapplyfortheinnovationsbeingtestedthroughtheVBIDmodel.VBIDgivesMAplanstheabilitytofurthertailorbenefitdesigntowardsenrolleesbasedonchronicconditionsandsocioeconomiccharacteristics,suchaseligibilityforLowincomeSubsidypaymentsordual-eligibility.

• Additionally,theVBIDmodelfor2020willallowparticipatingMAplanstoproposeusingtelehealthservicesinsteadofin-personvisits.

• ParticipatingMAplanswillalsoberequiredtoofferenrolleesimprovedandtimelyaccesstoWellnessandHealthCarePlanning(WHP),includingadvancecareplanning.CMMIisacceptingapplicationstoparticipateinthe2020VBIDModelthroughMarch1,2019.


6969

PartD:RiskSharingProposal• AnewPartDModelwillallowfor(1)enhancedrisksharingbetweenPartDplansandCMS,and(2)thecreationofnewflexibilitiesandincentivesforplans,providersandbeneficiariestochooselowercostdrugs.BothstandalonePartDplansandMA-PartD(MA-PD)plansmayparticipateinthenewmodel.• CATASTROPHICRISK:PlansthatparticipateinthePartDModelwillassumegreaterriskinthecatastrophicphaseofPartDthantraditionalPartDplans.CMSwillcalculatethesharedsavings/lossesowedtoorbytheplanforagivencontractyearbyretrospectivelyestablishingaspendingtargetbenchmark.• CMSwillsetthebenchmarkattheamountofthefederalreinsurancesubsidy(80

percentofthePartDcatastrophicphasecostsafterrebate)thatCMSprojectsPartDplanswouldreceiveiftheywerenotparticipatinginthemodel.

• Planswithfederalreinsurancesubsidyspendingthatislowerthanthebenchmarkwillreceiveperformance-basedpaymentsthatarebasedonthetotalamountofsavings;planswithfederalreinsurancespendingthatishigherthanthebenchmarkwillowe10percentofthedifferencebacktoCMS.CMSwillcalculatesavingsorlossesattheparentorganizationlevel.

• PATIENTTOOLS:CMSalsomayallowtoolsforbeneficiaryuse,includingaPartDRewardsandIncentivesprogram,thatwillhelpbeneficiariesunderstandtheiroptions(forexample,genericorbiosimilarversusbrandnameoptionsthatareclinicallyequivalent)andout-of-pocketcosts,andhelpthembecomemoreactiveandengagedconsumers.Inaddition,planswillbeabletoproposedrugutilizationmanagementtechniquesaimedatchangingpatientchoicebehaviorforlowercostdrugs,assumingequalefficacy.


7070

PartD:Auto-shipProposed2020• TheDraftCY2020CallLetterwouldallowmailorderpharmaciestoauto-shiprefillstomembersundercertainconditions.Sincethe2014contractyear,CMShasrequiredPartDplansponsors(otherthannon- employergroupwaiverplans(EGWPs))toobtainpatientconsentpriortoshippingEACHrefillprescription.CMSproposesthat,forthe2020contractyear,PartDplansponsorswouldbepermittedtoauto-shiprefillsofdrugsthatamemberhasbeenonforatleastfourconsecutivemonths.TheDraftCY2020CallLetteroutlinesCMS'sexpectationsregardinganyauto-shipprogram,includingthefollowing:

• Beneficiarieswouldneedtoconfirmtheirenrollmentintheauto-shipprogramatleastannually.• Plansponsorswouldberequiredtosendtworeminderstothebeneficiarywellinadvanceofshipment(e.g.,

25and10daysprior).Thereminderscouldbebyphone,email,text,directmailingorother'comparablemeans'basedonpatientpreference.

• Memberswouldbepermittedtochoosetoparticipatefornone,allorsomeoftheirmedications.• Plansponsorswouldberequiredtorefundanyrefillsthatthebeneficiaryreportsasunneededorunwanted.

• Yikes!Whataboutthewaste?


7171

PartD:Sub-capitationProposed2020

• Intheirproposal,CMSaskedforcommentson"thebarriers,feasibility,andbenefits/drawbacks"ofincludingthecostofPartBandDdrugsinMAplans'riskarrangementswithnon-pharmacyproviders(e.g.,physiciangroupsoraccountablecareorganizations)inarequestforinformationsetoutintheDraftCY2020CallLetter.• CMSmaybeinterestedinestablishingtheadditionofthesePartBandPartDprescriptiondrugcostsinproviderriskarrangements,based,atleastinpart,onthestatutoryprohibitiononPartDplansponsorsrequiringpharmaciestotakeoninsurancerisk(inotherwords,thereisaprohibitiononsub- capitation).

• Bygivingnon-pharmacyprovidersafinancialincentivetomanageprescriptiondrugcosts,includingphysician-administereddrugs,CMShopesthatMAplansandPartDplansponsorswillbeableto"drivedownthecost"ofsuchdrugs.Thiscouldbeprettybad,ifpopularPartDplanspressurepracticesorhospitalstosub-capitateforPartBandPartDdrugs.


72

PartD:BenefitDesign2020


73

HCCRisk-AdjustmentReporting


7474

7

WhatisRiskAdjustment?

•MedicareAdvantageadjuststheirmonthlypercapitapaymentstoHealthPlanstotakeintoaccounttherelativehealthoftheirmembers;“RiskAdjustment.”• HealthPlansreceivelesspaymentforhealthiermembers/patientsandmoreforsickermembers.• Therelativehealthor“riskadjustmentfactor”isbasedondiagnoses(codeddata)submittedbytheHealthPlanintheprioryear.• The“risk”scorecomesfromtheweight(assignedvalue)oftheHierarchicalConditionCategories(HCC)


75

Cancer1)MetastasisCancer&Acute

Leukemia2)Lung,UpperDigestive

Tract,&OtherSevereCancers

3)Lymphatic,Head&Neck,Brain,&OtherCancers&Tumors

4)Breast,Prostate,Colorectal&OtherCancers&Tumors

Diabetes1)Diabetesw/RenalorPeripheralCirculatoryManifestation

2)Diabetesw/NeurologicorOtherSpecifiedManifestation

3)Diabetesw/AcuteComplications

4)Diabetesw/OphthalmologicorUnspecifiedManifestations

5)Diabetesw/oComplications

VascularDisease1)VascularDisease

w/Complications2)VascularDisease3)ChronicUlcerof

Skin,Exceptpressure(decubitus)

KidneyDisease1)DialysisStatus2)RenalFailure3)Nephritis

CMSModelCategoriesandHierarchies(HCCs)— examples


7676

COMPARISONOFHHSANDCMSMODELS

CMS Model HHS Model Implications

Attributes Age,gender,medicalconditions codedusingICD-10-CM

Age,gender,medicalconditionsandfinancialstatusforthosewhoqualifyforcostsharingreductions.Themodel alsoincludesdemographicattributesandproductinformation

Commercialriskadjustmentrequiresadditionaldatacapturefor demographics

DxCode Capture Medicalconditionshavetobetreated/addressedanddocumentedannuallyorneedtospecifythatthemembernolongerhasthe conditions

Chronicconditionsnotdocumentedannuallyarenotcapturedinrisk scores

Acceptable Codes Conditionsdocumentedduringface-to-faceencounterwithacceptedprovider types

Same,thereforeeasierinestablishingprovider practices

Acceptable Encounters Professional,inpatientand outpatient Same,thereforeeasierinestablishingprovider practices

Historical Conditions Codedandreportedconditionstransferwithmember

Nomember-leveldatatransferredbetween plans

Forcommercialriskadjustment,allconditionsneedtobedocumentedannuallyandwhenplan changes


7777

WHYISRISKADJUSTMENT DONE?• Riskadjustmentscores(alsoknownastheRiskAdjustmentFactororRAF)

arehigherforapatientwithgreaterdiseaseburden,lowerforahealthierpatient.

• EachpatienthasanRAFscorethatincludesbaselinedemographicelements(age/sexanddualeligibilitystatus)aswellasincrementalincreasesbasedonHCCdiagnosessubmittedonclaimsfromfacetofaceencounterswithqualifiedpractitionersduringthecalendaryear.

• HCCcodingisprospectiveinnature.TheworkdonethisyearsetstheRAFandsubsequentfundingfornext year.

• Diagnosiscodes,alongwithdemographics, reportedonyourclaimsdetermineapatient’sdiseaseburdenandriskscore.

• Chronicconditionsmustbereportedonceperyear.EachJanuary1,theRAwillreset,meaningyoumustreport.AllofyourMedicarepatientsareconsideredcompletelyhealthyuntildiagnosiscodesarereportedonclaims.


78

HCCExamples


7979

RiskAdjustment&HCCDocumentationBasics

• ‘Activetreatment’status:Conditionsthatarepresentandunresolvedorunlikelytoresolveneedtobedocumentedatleastannually. CMSconsiderstheconditionresolvedifnotevaluatedandcodedatleastonce/calendaryear.

• ‘Forever’codes– conditionsthatdonotgoawayandpatientsareexpectedtohaveforever,e.g.,amputation,transplant,alcoholisminremission,CHF(compensated)

• Maybe‘forever’codesinclude:ostomy,cirrhosis,diabetes,hepatitis,,paraplegia/quadriplegia(bespecific)

• “Historyof”or“Pastconditions”• Historyofcancerisused,ifnotinactivetreatmentanddoesnothaveactivedisease.

Canceronlong-termtherapyisactivecancerwhenthetherapyisnotprophylactic• HistoryofstrokeorCVA– documentdeficitsandhistoryofincident(e.g.,hemiplegia

secondarytoCVA)


8080

DIAGNOSISCODING Tips

• Documentationmustshowthatconditionwas:• Monitored– Signs,symptoms,diseaseprogression,disease regression• Evaluated– Testresults,medicationeffectiveness,responseto treatment• Assessed/Addressed– Orderingtests,discussion,reviewrecords,counseling

• Treated– Medications,therapies,other modalities

• Adiagnosiscodemayonlybereportedifitisexplicitlyrecorded inthemedical record:• Nocodingfrom superbills orlabresultsbythemselves• Treatmentisprimafasciaevidenceofadiagnosis– ifyouaretreating,ittherefore exists


8181

COMMONCODINGERRORS

• Electronicmedicalrecord(EMR)wasunauthenticated(notelectronicallysigned).

• HighestdegreeofspecificitywasnotassignedthemostpreciseICD-10tofullyexplaintonarrativedescriptionofthesymptomordiagnosisinthemedical chart.

• Manifestationsnotrecorded—particularlyindiabetes…• Documentationdoesnotindicatethediagnosisisbeing

monitored,evaluated,assessed/addressed,ortreated (MEAT).• Chronicconditions,suchashepatitisorrenalinsufficiency,arenot

documentedas chronic.• Chronicconditionsorstatuscodesaren’tdocumentedinthemedical

recordatleastonce per year.• Assumptionthatotherpeople’scodingappliestoyou.


8282

CapturetheConditionsAnnually!

•EachpatientisTOTALLYHEALTHY onJanuary1EVERYYEAR

•Amputationsgrowback!•COPDpatientshavehealthylungs!•Metastasesgoawaywithoutdirecttreatment!•Allkidneysfunctionflawlessly!•Colostomypatientshaveaperfectcolon!•Getthepicture?IFYOUDON’TDOCUMENTANDCODETHECONDITION,ITDIDN’THAPPEN!


8383

ToDo’sfor2019

• Areyoubillingforallservicesthatcanbereimbursedrightnow???

• SendanNDCforallpayers.Makesureit’sinthe5-4-2formatnomatterwhattheManufacturerwebsitesays.

• Fortheyourmajorpayers,knowwhenclaimssubmissionexpires.Youareleavingmoneyonthetable!!

• CheckouttheMedicallyUnlikelyEditseveryquarterathttps://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/MUE.html

• Trumpcaretemporaryplanschangethewayinsuranceisverified.Thingsyounowneedtoknow:• Ceilings/CAPS:Drugs,Annual,Lifetime• ObamacarePremiumChanges• Benefits—All10?

• MonitorMedicareAdvantagedrugapprovalchangesforStepTherapy.

• ReadmoreaboutHCCshere:http://bok.ahima.org/doc?oid=302516#.XIguPZNKh-U

• EnsureyouknowEACHTIMEthepatientcomesin—changeofemployment,insurance,premiumpayment.

• WatchforchangesinDrugReimbursement.ParticipateintheStruggle.


84

ThankYou!!!


85

Appendices:Benchmarks&MIPs/QPP


86

NationalBenchmarksCY2018


87

onPointfocalPoint®Data• Demographics

• 2200+physicians• 170practices• 2.573millionclaimsin2018• 392,000patients• 439Commercialplans

• Data• Drugclaimsonlyrealtime• Allothertransactionsbyreport• AlldataisforINSURANCEONLY


88

CollectionRatesfromAllowables

Percentage Category88.10% Overall Collection

Percentage

89.09% Drug Collection Percentage

91.22% RadOnc Collection Percentage

67.66% Imaging Collection Percentage

80.55% E/M Collection Percentage

Collection Percentage

NetCollection=Netofdenials,patientportions,anddiscounts


89

InsuranceAgingforAllItems&Services


90

DenialPercentage

Denial PercentCategory

15.85% Overall Denial Percentage

11.17% RadOnc Denial Percentage

18.86% Imaging Denial Percentage

11.67% E/M Denial Percentage

8.86%Drug Denial Percentage

Denial Percentage


91

DaysToPay

DaystoPay Category32 OverallDaysto

Pay33 RadOncDaysto

Pay32 ImagingDaysto

Pay29 E/MDaystoPay50 DrugDaystoPay

WithOutliers*:*Withoutoutliersitisabout31days


92

THEQPP&MIPSFINALRULEfor2019


9393

Quality Payment Program: Merit-based IncentivePaymentSystem(MIPS)Year3(2019)Final

MIPSeligible cliniciansinclude:• Physicians• Physician Assistants• Nurse Practitioners• ClinicalNurse Specialists• CertifiedRegisterNurseAnesthetists

• Groupsofsuch clinicians

MIPSEligibleClinician Types:

Year2 (2018) Final Year3(2019) Final

MIPSeligibleclinicians include:• Same fivecliniciantypesfromYear2 (2018)

AND:• Clinical Psychologists• Physical Therapists• Occupational Therapists• Speech-Language Pathologists• Audiologists• RegisteredDieticiansorNutritionProfessionals 19


9494

QPP:MIPSYear3(2019)FinalLow-VolumeThreshold Determinations:

1. Addedathirdelement– NumberofServices– tothelow-volumethresholddetermination criteria

• Thefinalizedcriteria include:

• Dollaramount- $90,000incoveredprofessionalservicesunderthePhysicianFeeSchedule(PFS)

• Numberofbeneficiaries– 200MedicarePartBbeneficiaries

• Numberofservices(New)– 200coveredprofessionalservicesunderthe PFS

2. Addedanopt-inoptionforYear 3

• IfyouareaMIPSeligibleclinicianandmeetorexceedatleastone,butnotall,ofthelow-volumethresholdcriteria,youmay opt-into MIPS

• Ifyouopt-in,you’llbesubjecttotheMIPSperformancerequirements,MIPSpaymentadjustment,etc.


9595

QPP:MIPSYear3(2019)Final

PerformanceCategoryWeights:

Performance CategoryPerformanceCategoryWeights

Year1 (2017) Year2 (2018) Year3(2019)– Final

Quality

60% 50% 45%

Cost

0% 10% 15%

Improvement Activities

15% 15% 15%

PromotingInteroperability

25% 25% 25%


9696


PerformanceCategories– AdditionalHigh-LevelChanges:Quality:RemovedcertainmeasuresasapartoftheMeaningfulMeasuresInitiativeandshiftedthe small practicebonus(worth6points)fromthefinalscorecalculationintothisperformance category

Cost: Added8newepisode measures

Facility-basedqualityandcostmeasures:Clinicianswhoarehospital-basedcanusetheirhospital’sperformanceundertheHospitalValue-BasedPurchasing(VBP)ProgramfortheMIPSqualityandcostperformancecategories

ImprovementActivities:RefinementsmadetotheImprovementActivities inventory

PromotingInteroperability:Overhauledthecategorytosimplify,focusoninteroperability,align clinicianpolicieswithhospitalpolicies,reducemeasures,andchangescoringtobefocusedon performance


9797

QPP:MIPSYear3(2019)FinalSubmittingData:

Collectiontype- asetofqualitymeasureswithcomparablespecificationsanddatacompletenesscriteria,asapplicable,including,butnotlimitedto:electronicclinicalqualitymeasures(eCQMs);MIPSClinicalQualityMeasures*(MIPSCQMs);QualifiedClinicalDataRegistry(QCDR)measures;MedicarePartBclaimsmeasures;CMSWebInterfacemeasures;theCAHPSforMIPSsurvey;andadministrativeclaims measures

Submissiontype- themechanismbywhichasubmittertypesubmitsdatatoCMS,including:direct,loginandupload,log inandattest,MedicarePartBclaims,andtheCMSWeb Interface

• TheMedicarePartBclaimssubmissiontypeisforindividualcliniciansorgroupsinsmallpracticesonly tocontinueprovidingreporting flexibility

Submittertype- theMIPSeligibleclinician,group,virtualgroup,orthirdpartyintermediaryactingonbehalfofaMIPSeligibleclinician,group,orvirtualgroup,asapplicable,thatsubmitsdataonmeasuresandactivitiesunder MIPS

*ThetermMIPSCQM replaces whatwasformerlyreferredtoas“registrymeasures”sincecliniciansthatdon’tusearegistry maysubmitdataonthese measures


9898


PerformanceThresholdandPayment Adjustment:

*Paymentadjustment(andexceptionalperformerbonus)isbasedoncomparingfinalscoretoperformancethresholdandadditionalperformancethresholdforexceptionalperformance.Toensurebudgetneutrality,positiveMIPSpaymentadjustmentfactorsarelikelytobeincreasedordecreasedbyanamountcalleda“scalingfactor.”TheamountofthescalingfactordependsonthedistributionoffinalscoresacrossallMIPSeligible clinicians.

Performance Period Performance ThresholdExceptionalPerformance

BonusPayment Adjustment*

Year1 (2017) 3 points 70points Upto +4%

Year2 (2018) 15 points 70 points Upto +5%

Year3(2019)- Final 30points 75points Upto +7%


9999

QualityPaymentProgram:AdvancedAlternativePaymentModels(APMs)Year3(2019)Final

General:

• IncreasedtheAdvancedAPMCEHRTthresholdsothatanAdvancedAPMmustrequirethatatleast75% ofeligiblecliniciansineachAPMEntityuse CEHRT

• Extendedthe8%revenue-basednominalamountstandardforAdvancedAPMsthroughperformanceyear2024

• StreamlinedthedefinitionofaMIPScomparable measure

MIPSAPMsandtheAPMScoring Standard:

• ReorderedthewordingofthecriteriontostatethattheAPM“basespaymentonqualitymeasures andcost/utilization”toclarifythatthecost/utilizationpartofthepolicyisbroaderthanspecificallyrequiring theuseofacost/utilization measure

• UpdatedtheMIPSAPMmeasuresetsthatapplyforpurposesoftheAPMscoring standard


100100

QPP:AdvancedAPMsYear3(2019)Final

All-PayerCombination Option:• IncreasedflexibilityfortheAll-PayerCombinationOptionandOtherPayerAdvanced

APMsfor non-MedicarepayerstoparticipateintheQualityPayment Program

• Established a multi-year determination process where payers and eligible clinicianscan provide information on the length of the agreement as part of their initial OtherPayer Advanced APM submission, and have any resulting determination be effectivefor the duration of the agreement

• Allowing QP determinations at the TIN level in addition to the APM Entity andindividual eligible clinician levels in certain instances when all eligible clinicians whohave reassigned their billing rights to the TIN are included in a single APM Entity

• Permittingallpayertypestobeincludedinthe2019PayerInitiatedOtherPayerAdvancedAPMdeterminationprocessforthe2020QPPerformance Period

• IncreasedtheCEHRTusecriterionthresholdsothatinordertoqualityasanOtherPayerAdvancedAPMasofJanuary1,2020,CEHRTmustbeusedbyatleast75%ofeligiblecliniciansintheotherpayer arrangement

• Maintainedtherevenue-basednominalamountstandardforOtherPayerAdvancedAPMsat8% through performanceperiod 2024

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