What You Need to Know About the Quality Payment Program, Year 3

Posted on 7 Dec, 2018 |comments_icon 0|By Bruce Pegg

SPOILER ALERT: More shake ups, reductions, and rebalancing for 2019.

The Centers for Medicare & Medicaid Services (CMS) released revisions to payment policies under the Medicare Physician Fee Schedule (MPFS) for the Quality Payment Program (QPP) for calendar year 2019.

“The Year 3 policies are reflective of the feedback we received from many stakeholders including overall burden reduction, improving patient outcomes and reducing burden through meaningful measures and expanding participation options to other clinicians,” CMS noted in as described by CMS in its Quality Payment Program Year 3: Final Rule Overview fact sheet.

But many stakeholders — namely clinicians — are scratching their heads, wondering, “Burden reduction for whom?“

Indeed. While announcing the final rule’s release, CMS Administrator Seema Verma spoke to head off stakeholder complaints. “This does not deter us,” she said. “The status quo, where nearly one in five dollars will be spent on healthcare, is unacceptable. If we’re going to move our system to a patient-centered, value-based system, change is inevitable, and change is always hard for those whose livelihood is dependent on the status quo.”

And so, without further ado, let’s look at some key policy revisions that will impact your organization in 2019.

Learn Who’s In and Who’s Out

Once again, MIPS eligibility, exclusions, and exemptions have been redefined.

Eligibility: In addition to physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and groups of such clinicians, Year 3 adds the following to the list of MIPS eligible clinicians:

  • Physical therapists
  • Occupational therapists
  • Speech-language pathologists
  • Audiologists
  • Clinical psychologists
  • Registered dietitian or nutrition professionals

Exclusions: Year 3 of the MIPS program adds a third criterion for clinicians to qualify for the low-volume threshold: as follows:

  • Have $90,000 or less in Part B allowed charges for covered professional services
  • Provide care to 200 or fewer beneficiaries
  • New: Provide 200 or fewer covered professional services under the PFS

Exemptions: If you don’t meet or exceed all three low-volume threshold criteria in 2019, you may opt-in to MIPS if you meet or exceed one criteria.

Gear Up for Revamped Categories

Among the policy changes detailed in the final rule, a number impact EHRs and the MIPS IT category, Promoting Interoperability (PI), which replaced Advancing Care Information (ACI) and Meaningful Use (MU) earlier this year.

“Today’s rule finalized changes to help make EHR tools that actually support efficient care instead of hindering care,” Verma commented.

But beyond EHR upgrades, no category (Cost, Quality, Improvement Activities, or PI) has been spared CMS tinkering. Some have been tweaked while others have been completely revamped — all in the name of reducing providers’ burdens.

Highlights include reweighting Quality and Cost, removing PI-type measures from Improvement Activities, and revising measures and the scoring methodology for the tech component, to name a few.

The MIPS PI updates, in particular, will present challenges to earning performance incentives. Several measures have been removed, which simplifies the scoring but at the expense of the flexibility these options had offered. Compared to MIPS ACI, clinicians will find MIPS PI tougher to earn a perfect score.

Other noteworthy QPP policy changes effective in CY 2019 include:

  • Help for small practices. CMS finalized a six-point bonus for small practices and parked it in the Quality category rather than adding it to the composite score.
  • Require more of Advanced APMs. Changes abound for Advanced APMs, including a mandate that 75 percent of Advanced APM providers upgrade to the latest editions of “CEHRT to document and communicate clinical care with patients and other health care professionals,” the QPP Year 3 fact sheet notes.
  • Update facility-based scoring for MIPS providers. “CMS is providing the option for clinicians who are based at a healthcare facility to use facility-based scoring to reduce the burden of having to report separately from their facility,” said Verma.

Contributing Editor: Kristin Webb-Hollering

Learn More

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Bruce Pegg
Editor, Newsletters

An experienced teacher and published author, Bruce is TCI’s new voice of primary care, delivering advice and insights every month for coders in the fields of family, internal, and pediatric medicine through Primary Care Coding Alert and Pediatric Coding Alert. Additionally, he is the current editor of E/M Coding Alert. Bruce has a Bachelor of Arts degree from Loughborough University in England and a Master of Arts degree from The College at Brockport, State University of New York. He recently became a Certified Professional Coder (CPC®), credentialed through AAPC.

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