Below are notices, milestones and resources to help you navigate payment changes in the Quality Payment Program (PPQ), the Medicare Access and CHIP Reauthorization Act (MACRA), and more.
Earlier this month, Congress adopted legislation that updated the Medicare Physician Fee Schedule (MPFS) conversion factor for claims processed from March 9 to December 31, 2024. The revised conversion factor has been updated to $33.29 reflecting a 1.68% increase from the previous conversion factor. Since the conversion factor is not retroactive, CMS will not reprocess claims already submitted. View the updated MPFS payment rates for the remainder of 2024.
Last week, Congress passed legislation to provide some relief from the Medicare physician payment cuts that took effect earlier this year. On January 1, CMS instituted a 3.37% cut to all Medicare physician payments. The legislation passed by Congress will reduce this cut by about half (1.68%) which will provide some relief. The Endocrine Society continues to urge Congress to pass comprehensive physician payment reform legislation to provide physicians with adequate reimbursement. We have urged Congress to pass legislation providing an inflation-based payment update based on the full Medicare Economic Index.
The Centers for Medicare and Medicaid Services (CMS) announced that it will offer assistance to providers affected by the cyberattack on Change Healthcare. These payments are an advance to help providers and suppliers meet their obligations, but it is important to note that the payments are not a loan and cannot be forgiven. For more information, see our summary. CMS distributed additional resources to provide guidance regarding connecting with payers, advanced payments, and payer resources.
The Centers for Medicare and Medicaid Services (CMS) finalized the implementation of G2211, a complex add-on code that can be used by endocrinologists to pay for complex care services delivered by a provider with an ongoing relationship with the patient. The Endocrine Society created a guidance document on the code. The Endocrine Society also hosted a webinar to explain how endocrinologists can properly use this code and created an "FAQ" sheet with answers to all questions asked; watch the recording of the webinar.
The Centers for Medicare and Medicaid Services (CMS) released a final rule that outlines policy changes to the prior authorization process for state and federal health plans. Read our summary of the final rule.
CMS released the final CY 2024 Medicare Physician Fee Schedule rule. The Endocrine Society commented on the proposed rule which was released in July. Read our summary of the final rule here.
CMS released the CY 2024 Medicare Physician Fee Schedule proposed rule and factsheet. The Endocrine Society will be developing comments on the proposed rule, which are due September 11. Read our summary of the proposal.
The Centers for Medicare & Medicaid Services (CMS) released a proposed rule that outlines policy changes to the prior authorization (PA) process for several of the agency’s benefit programs. The rule will help alleviate burdensome procedures of prior authorization by streamlining the process for both patients and providers. Read the proposed rule summary.
November 1, 2022: CY 2023 Medicare Physician Fee Schedule Rule
CMS released the CY 2023 Medicare Physician Schedule (MPFS) rule. Read our summary of the rule.
July 7, 2022: CY 2023 Medicare Physician Fee Schedule Proposed Rule
CMS released the CY 2023 Medicare Physician Fee Schedule (MPFS) proposed rule and fact sheet. Read our detailed summary or one-pager for more information.
December 15, 2021: Surprise Billing Requirements
Beginning January 1, 2022, new requirements will go into effect for healthcare providers to protect patients from surprise bills. Read our fact sheet for more details.
Physicians are facing the “perfect storm,” which will bring almost a 10 percent cut in Medicare reimbursement on January 1, 2022. Congress must act to avert this cut because the administration does not have the authority to do so. Learn more.
We delivered a briefing titled "Legislation & Regulations Affecting Endocrinologists: What You Need to Know About Medicare Physician Payment, Telehealth Expansion, and Drug Pricing." Watch a recording.
Click here for a summary created by the Endocrine Society of the calendar year 2022 proposed Physician Fee Schedule.
Senate Reaches Deal to Avert Medicare Cuts
As you may know, a two percent reduction in Medicare payments to providers was scheduled to go into effect on April 1st. Last week, the U.S. Senate overwhelmingly passed an agreement to avert these cuts. The legislation will delay these reimbursement cuts through the end of 2021. The House of Representatives is expected to vote on the legislation the week of April 12.In anticipation of this possible Congressional action, the Centers for Medicare and Medicaid Services (CMS) has instructed the Medicare Administrative Contractors (MACs) to hold all claims with dates of service on or after April 1, 2021, for a short period without affecting providers’ cash flow. This will minimize the volume of claims the MACs must reprocess when Congress extends the suspension of the Medicare cuts; the MACs also will automatically reprocess any claims paid with the reduction applied, if necessary.
Society Makes Important Change to E/M Requirement at CPT Panel
Earlier this month, the American Medical Association’s CPT Panel released technical corrections to the outpatient E/M documents requirements, which included a change to remove proposed limits on how insulin would have been considered when being monitored. The Endocrine Society advocated for this change and worked with AACE to revise this language at the February CPT meeting. The changes are retroactive to January 1st, 2021.
FAQs on Coding and Billing for 99091 and 99457
The Endocrine Society has worked to help our members determine how to appropriately bill for the work delivered to patients with insulin pumps. Recently, we sent information with clarification by CMS on coding and billing for remote physiologic monitoring (RPM) codes 99091 and 99457 and specifically how these codes could be used to reimburse for the care delivered to insulin pump patients. We have developed an FAQ document to help you navigate these changes and answer any questions you may have about coding and billing for these codes. You can view the FAQ document here.
The Endocrine Society has been working to help members determine how to appropriately bill for the work delivered to patients with insulin pumps. Since January 1, 2019, Medicare has been paid for remote physiologic monitoring (RPM) services since January 1, 2019, but there has been confusion regarding how these services may apply to care associated with insulin pumps. Read our explanation here.
On December 1, the Centers for Medicare & Medicaid Services (CMS) released the Medicare Physician Fee Schedule (MPFS) final rule for CY 2021. This rule updates payment policies and payment rates for Part B services furnished under the MPFS, as well as makes changes to the Quality Payment Program (QPP). See below for summary and analysis of the rule:
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) ended the Sustainable Growth Rate formula for Medicare reimbursement. For eligible clinicians, the Quality Payment Program (QPP) replaces previous Medicare Part B payment programs with the Merit-based Incentive Payment Program (MIPS) and Advanced Alternative Payment Models (Advanced APMs). Explore information and resources to learn how this affects your practice. Questions? Email us at [email protected].
SPOTLIGHT: Quality Payment Program Resource Library
The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 is legislation that established a new payment system for doctors who treat Medicare patients, changing the way Medicare doctors are reimbursed. Under MACRA, the Sustainable Growth Rate (SGR) Formula was repealed, and providers are instead paid based on the quality and effectiveness of the care they provide.
Quality Payment Program (QPP) is the name of the Medicare payment program set in place by MACRA. QPP allows Medicare providers to choose one of two payment tracks: Merit-based Incentive Payment System (MIPS) or Advanced Alternative Payment Models (Advanced APMs).
You can find out whether you are part of the QPP by entering your provider number into the tool on this page: qpp.cms.gov/learn/eligibility. Providers are part of the QPP if:
There is additional technical support available for practices in Small, Rural and Health Professional Shortage Areas (HPSAs). If you meet the eligibility requirements above, you must begin participation in the QPP on January 1 of the reporting year. Performance data for Year 1 must be submitted by March 31, 2018 in order to avoid a payment penalty.
The Merit-based Incentive Payment System (MIPS) uses performance-based measures to determine Medicare payment adjustments. Medicare will use the four categories below to determine whether eligible physicians participating in MIPS will receive a positive, negative, or neutral payment adjustment to their Medicare payments. Click on the icons below to select and download the measurement CSV files for Quality, Advancing Care Information, and Improvement Activities. Fora full list of measures for each category, please see the links below.
Quality (45%)
Replaces PQRS. Report at least six measures for the full calendar year.
Advancing Care Information (25%)—Replaces Medicare EHR Incentive Program (Meaningful Use). Fulfill the required measures for a minimum of 90 days.
Improvement Activities (15%)mdash;110+ activities focused on care coordination, beneficiary engagement, and patient safety. Attest that you completed up to 4 Improvement Activities for a minimum of 90 days.
Cost (15%)mdash;Replaces Value-Based Modifier. No data submission required. Calculated from adjudicated claims.
You may be exempt from MIPS if you participate in an alternative payment model. Alternative Payment Models (APMs) are payment approaches that give incentives for high-quality and cost-efficient care. Advanced APMs are a type of APM that allow practices to take on some risk related to patient outcomes. To find Advanced APMs accepting enrollment, please visit innovation.cms.gov.
In 2019, clinicians who participate in one of the Advanced APMs listed below will be exempt from the MIPS reporting requirements and will receive a 5% payment bonus from 2019 – 2024. If you leave an Advanced APM during 2018, make sure you have met the Advanced APM threshold or submit MIPS data to avoid a penalty.
Quality Payment Program—A regularly updated resource to help eligible providers understand QPP components. Includes:
Transforming Clinical Practice Initiative—The initiative is one part of a strategy advanced by the Affordable Care Act to strengthen the quality of patient care and spend health care dollars more wisely.
Support for Small Practices—List of QPP technical assistance by region for practices with 15 or fewer clinicians.
MIPS Action Plan—A resource for physicians not yet participating in the new Medicare payment program is designed to help practices prepare for, and operate under, the regulation.
Preparing Your Practice for Value-based Care—This module will help the user transition to a value-based care model.
Inside Medicare's New Payment System (Podcast Series)—Podcasts presented by ReachMD that cover various topics related to QPP, such as MACRA for small practices and how to use an EHR to participate in MACRA
MACRA and the Quality Payment Program resource center
MACRA—Medicare Access and CHIP Reauthorization Act of 2015 is landmark legislation that changes how Medicare pays physicians.
QPP—Quality Payment Program is the new Medicare Part B payment program focused on care quality.
MIPS—Merit-based Incentive Payment System is the payment system for eligible clinicians who are not participating in an Advanced APM. The payments in MIPS are based on four categories: Quality, Improvement Activities, Advancing Care Information, and Cost.
APM—An Advanced Payment Model is a payment approach that gives added incentive payments to provide high-quality and cost-efficient care.
Advanced APM—Advanced Alternative Payment Models are a subset of APMs that let practices earn more for taking on some risk related to their patients' outcomes.
CMS—Centers for Medicare & Medicaid Services is a US federal agency under the Department of Health and Human Services which administers Medicare, Medicaid, and the State Children's Health Insurance Program.
HHS—United States Department of Health and Human Services
Join our endocrine community and become a member! Only members receive access to a variety of member benefits that will enhance your career. If your membership has lapsed, rejoin today so that you can continue to receive your membership benefits.