QPP and MACRA

Resource to Navigate Changes in Medicare Payments

August 10, 2021: CY 2022 Physician Fee Schedule Proposed Rule Summary

Click here for a summary created by the Endocrine Society of the calendar year 2022 proposed Physician Fee Schedule.

April 1, 2021: Endocrine Society Physician Payment Updates

Senate Reaches Deal to Avert Medicare Cuts

As you may know, two percent reduction in Medicare payments to providers was scheduled to go into effect on April 1stLast 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 toE/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 codesYou can view the FAQ document here.

 

Update: Billing Medicare for Treating Patients with Insulin Pumps

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. 

UPDATE: CMS Releases Physician Payment Final Rule for CY 2021

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

QPP/MACRA

What is MACRA?

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.

What is the Quality Payment Program?

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).

How does this affect me or my practice?

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:

  • You participate in an Advanced APM or
  • You bill Medicare more than $90,000 in Part B allowed charges per year OR provide care for more than 200 Medicare patients per year

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.


MIPS

Understanding the Measurement Criteria and Reporting Requirements

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. 

QualityQuality (45%)
Replaces PQRS. Report at least six measures for the full calendar year.

Advancing Care InformationAdvancing Care Information (25%)—Replaces Medicare EHR Incentive Program (Meaningful Use). Fulfill the required measures for a minimum of 90 days.

Improvement ActivitiesImprovement 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.

CostCost (15%)mdash;Replaces Value-Based Modifier. No data submission required. Calculated from adjudicated claims.


Advanced APMs

Participating in Advanced APMs

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.

Qualifying Advanced APMs


Resources

Endocrine Society Resources

Centers for Medicare & Medicaid Services

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.

American Medical Association

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

American College of Physicians

MACRA and the Quality Payment Program resource center


Glossary

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

Journals

The Best of Endocrine Society Journals 2020

Explore a collection of top articles published in the Endocrine Society journals in 2020, selected on the basis of citations, downloads, and Altmetric score.

Explore a collection of top articles published in the Endocrine Society journals in 2020, selected on the basis of citations, downloads, and Altmetric score.

CEU 2021

CEU 2021 Claiming Credits

Evaluations are now open. Visit the CEU 2021 landing page to learn how you can claim credits and certificate of participation. Evaluations must be completed by December 31, 2021 to receive credit.

Evaluations are now open. Visit the CEU 2021 landing page to learn how you can claim credits and certificate of participation. Evaluations must be completed by December 31, 2021 to receive credit.

Membership

Become a Member

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.

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.

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