IN THIS ISSUE
- Upcoming Events
- Small Practice Spotlight – Professional Medical Associates
- Extreme and Uncontrollable Circumstances Exception for COVID-19
- CMS Releases 2021 Proposed Rule for the Quality Payment Program
- May LAN Q&A: Understanding How to Implement Telehealth Services
- How to conduct a Virtual Annual Wellness Visit
- How to Engage Specialists in MIPS
- Monthly Observance – National Immunization Awareness Month
INFORMATION REGARDING UPCOMING EVENTS:
Upcoming Webinar: Maximizing Your MIPS Score: Advice for Solo and Small Group Practices
- Tuesday, September 15, 2020, 3:30 p.m. – 4:30 p.m. ET
- Thursday, September 17, 2020, 11:00 a.m. – 12:00 p.m. ET
Additional Upcoming Events and Links to Past Events
- Upcoming and past CMS events related to MACRA, MIPS, and APMs: https://qpp.cms.gov/about/webinars
- Past QPP SURS events: https://qppsurs.com/webinar-resources/
- CMS Podcasts and Transcripts of Coronavirus COVID-19 Stakeholder Calls: https://www.cms.gov/Outreach-and-Education/Outreach/OpenDoorForums/PodcastAndTranscripts
Small Practice Spotlight – Professional Medical Associates
Dr. Beverly Jordan is a physician at Professional Medical Associates, a small family medicine practice in Enterprise, Alabama. As a result of the pandemic, Dr. Jordan estimates her practice lost approximately 70 percent of its patient caseload overnight and had to quickly transition to telehealth. Many of Dr. Jordan’s patients do not have the technology or internet access to participate in telehealth visits. Dr. Jordan shared her practice’s experience adjusting to the COVID-19 pandemic during a Virtual Town Hall webinar held on May 13, 2020 by the American Academy of Family Physicians (AAFP). Her strategies for transforming her office workflow and partnering with the community to adapt to COVID-19 are shared below:
1) Build relationships with community – The community of Enterprise, Alabama played a central role in helping Dr. Jordan’s practice obtain the personal protective equipment (PPE) they needed to safely treat patients. Dr. Jordan’s practice quickly ran out of goggles and face shields and had to think creatively about how to obtain needed safety supplies. Dr. Jordan heard that the University of Alabama was using a 3D printer to produce face shields for its medical school. By connecting the university with the local high school in Enterprise, which had a career technology center and 3D printer, students at the high school were able to print face shields for Dr. Jordan’s practice. The practice also received PPE donations from local dentists and orthodontists that were forced to shut down during the pandemic. While Dr. Jordan would never have imagined she would need to ask her community for supplies, she was incredibly grateful that her town stepped in to make sure she could continue to safely treat patients.
2) Change your office workflow– Dr. Jordan’s practice has changed its daily workflow in response to the pandemic. The staff prepares for telehealth visits first thing in the morning and then sees patients who are sick in the afternoon. The practice transitioned to a parking lot waiting room system, allowing patients to check in from the parking lot by telephone. Dr. Jordan’s practice also offers curbside coronavirus testing for the entire community. While her patient caseload has substantially decreased, Dr. Jordan mentioned that a silver lining is that she has more time to train her staff on scribing, or documenting patient information and notes from the patient-physician encounter so that the provider can focus on patient care.
3) Use videos and social media to keep patients in the loop – To help inform patients about their options for receiving care, Dr. Jordan’s practice began recording videos on social media, including videos on how to connect devices to the internet and how to log in to the telehealth platform. The practice uses social media, including Facebook Live, to alert its patients to any coronavirus updates (including why it is important to wear a mask) and to answer questions. The Facebook Live sessions have been extremely popular and patients often call the office to inquire when the next session will be.
While the pandemic has challenged Dr. Jordan’s practice, she relies on her relationships in the community and has reached out to local legislators to advocate for the needs of physicians in her town. Dr. Jordan hopes that this crisis shines a true light on health disparities in rural America, and that these disparities can be corrected through better broadband access so that more rural patients can access health care services via telehealth. Click here to view an on-demand recording of Dr. Jordan’s webinar held on May 13, 2020.
Extreme and Uncontrollable Circumstances Exception for COVID-19
For the 2020 performance year, CMS will use the extreme and uncontrollable circumstances policy to allow clinicians, group practices, and virtual groups to request reweighting of any or all performance categories if they have been affected by the current COVID-19 public health emergency.
You might consider applying for the exception if the COVID-19 pandemic is preventing you from collecting data for an extended period, or if it hampers your ability to meet requirements for the cost performance category. The extreme and uncontrollable circumstances application for performance year 2020 is currently open and will close December 31, 2020. Key details of this exception policy include:
- The exception is not automatic; you must apply for the extreme and uncontrollable circumstances exception for the 2020 performance year. If you do not apply, or if your application is not approved, you are responsible for submitting your 2020 MIPS data and will receive a payment adjustment based on your performance. This is a change from the policy for performance year 2019.
- If your application is approved, you do not have to report data for the requested MIPS performance category or categories, and those categories will be re-weighted. If fewer than 2 performance categories can be scored, the clinician, group, or virtual group will receive a neutral payment adjustment in the 2022 payment year.
- Regardless of whether you have an approved exception application, you can still choose to report. If you submit data for two or more MIPS performance categories, you will receive a final score based on your performance in these categories.
Beginning with the 2020 performance year, you will need a HCQIS Access Roles and Profile (HARP) account to submit an extreme and uncontrollable circumstances application. For additional information on eligibility for the extreme and uncontrollable circumstances exception and how to apply, see the QPP COVID-19 Response and the QPP Exceptions pages. For more information on what CMS is doing to address the COVID-19 pandemic, see the Current Emergencies page.
If you have questions about the extreme and uncontrollable circumstances exception or about reporting your 2020 MIPS data, do not hesitate to contact your Technical Assistance Contractor. To find your Technical Assistance Contractor, click here.
CMS Releases 2021 Proposed Rule for the Quality Payment Program
On August 3rd, CMS released its proposed policies for the 2021 performance year of the Quality Payment Program via the Medicare Physician Fee Schedule (PFS) Notice of Proposed Rulemaking (NPRM). You can review the Proposed Rule here.
Key proposals for the 2021 performance year of the Quality Payment Program include:
- Beginning Merit-based Incentive Payment System (MIPS) Value Pathways (MVPs) implementation in 2022 instead of 2021
- Increasing the performance threshold from 45 points for the 2020 performance year to 50 points for 2021 (but 10 points less than the 60-point threshold finalized for 2021 in the CY 2020 PFS Rule)
- Revising performance category weights for Quality (decreases from 45% to 40%) and Cost (increases from 15% to 20%)
- Removing the CMS Web Interface as a collection type and submission type for reporting MIPS quality measures beginning with the 2021 performance period
- Sunsetting the Alternative Payment Model (APM) Scoring Standard and allowing MIPS-eligible clinicians in APMs the option to participate in MIPS and submit data at the individual, group, or APM Entity level
- Updating third party intermediary approval criteria as well as remedial action and termination criteria
New APM Performance Pathway (APP) in 2021: Based on stakeholder feedback, CMS also proposes implementing an APP in 2021 that would be:
- Complementary to MVPs, composed of a fixed set of measures for each performance category
- Available only for MIPS-eligible clinicians in MIPS APMs
- Reported by individual eligible clinicians, groups, or APM Entities
Performance category weights under the APP would be: 50% for Quality, 30% for Promoting Interoperability, and 20% for Improvement Activities.
Key proposals for the Medicare Shared Savings Program include:
- For performance year 2020, waiving the requirement for ACOs to field a Consumer Assessment of Healthcare Providers and Systems (CAHPS) for ACOs survey and providing ACOs automatic full credit for CAHPS. In addition, CMS is seeking comment on an alternative scoring methodology approach under the extreme and uncontrollable circumstances policy for performance year 2020.
- For performance year 2021, requiring ACOs participating in the Shared Savings Program to report quality via the APP for purposes of determining shared savings and losses, instead of via the CMS Web Interface, and reducing the number of measures ACOs are required to actively report from 10 to 3 while increasing the focus on patient outcomes.
- Updating the quality performance standard, requiring ACOs to receive a quality score equivalent to the 40th percentile or above across all MIPS Quality performance category scores, and allowing ACOs that meet or exceed the threshold their maximum sharing rate or avoid owing maximum losses.
Complex Patient Bonus COVID-19 Update in 2020: In addition to 2021 policies, this NPRM includes a proposal to increase the complex patient bonus from a 5- to 10-point maximum for clinicians, groups, virtual groups, and APM Entities for 2020 performance only to offset the additional complexity of their patient population due to COVID-19. Learn more about additional flexibilities implemented in response to the public health emergency on the QPP COVID-19 Response webpage.
You can review the 2021 Quality Payment Program Proposed Rule Fact Sheet, for a high-level overview of policy changes to the Quality Payment Program being proposed for the 2021 performance year.
CMS is seeking comment on a variety of proposals in the NPRM. Comments are due by 5 p.m. Eastern Daylight Time (EDT) on October 5, 2020. You must officially submit your comments in one of the following ways:
- Electronically, through Regulations.gov
- Regular mail
- Express or overnight mail
Note: As with other rules, CMS is publishing this proposed rule to meet the legal requirements to update Medicare payment policies in the PFS on an annual basis. In recognition of the 2019 Coronavirus (COVID-19) public health emergency and limited capacity of healthcare providers to review and provide comment on extensive proposals, CMS has limited annual rulemaking required by statute to focus primarily on essential policies including Medicare payment to providers, as well as proposals that reduce burden and may help providers in the COVID-19 response.
May LAN Q&A: Understanding How to Implement Telehealth Services
The following questions were among those asked by the attendees of the May 2020 LAN webinar, entitled “2020 Understanding How to Implement Telehealth Services: Implications for Solo and Small Group Practices.” The answers have been edited here for length and context. For access to the full Q&A document and previous LAN webinar presentations, see the QPP SURS website.
1) Insurance providers covering behavioral health services have informed us to use the modifier code GT or 95. What is the difference between the two modifiers?
Medicare previously required providers to submit claims for telehealth services using the appropriate procedure code along with the telehealth GT modifier (“via interactive audio and video telecommunications systems”) or GQ modifier (“via an asynchronous (delayed communications) telecommunications system”). As of January 1, 2018, the GT modifier is only allowed on institutional claims billed under Critical Access Hospital (CAH) Method II.
Up until March 1, 2020, providers were instead asked to use the place of service (POS) code 02 to identify telehealth services. However, according to the AMA COVID-19 pandemic telehealth fact sheet, with the passage of the CARES Act, all office-based physicians should use their usual POS code to be paid at the non-facility rate for telehealth services and add modifier 95 to telehealth claim lines.
2) What platforms can you use for telehealth?
Many third-party vendors offer platforms that are advertised as HIPAA compliant, including Skype for Business/Microsoft Teams, Updox, VSee, Zoom for Healthcare, Doxy.me, Google G Suite Hangouts Meet, and Cisco Webex Meetings/Webex Teams. Many EHRs also offer telehealth tools which may be discounted for existing customers, and offer the benefit of integration with your health record system.
Under the Notice of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency, covered health care providers can use popular applications that allow for video chats, including Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, Zoom, or Skype, to provide telehealth without risk that the Office of Civil Rights might seek to impose a penalty for noncompliance with the HIPAA Rules related to the good faith provision of telehealth during the COVID-19 nationwide public health emergency. Providers are encouraged to notify patients that these third-party applications potentially introduce privacy risks, and providers should enable all available encryption and privacy modes when using such applications.
3) If you cannot gather vital sign data (e.g., blood pressure, weight), how does this affect MIPS measures?
Participants may self-report vital signs and other data for Medicare Annual Wellness Visits (AWVs) done via telehealth. This is particularly helpful for patients with conditions like hypertension, diabetes, and other high-need patients to have their measurements ready for the appointment. During the May 12 COVID-19 Office Hours call, CMS staff shared that further guidance will be released in the near future that will instruct providers on what to do when patients are unable to collect their own measurements. In cases where patients cannot self-report vital sign information, you may need to consider choosing MIPS measures that are more compatible with your telehealth practices.
How to conduct a Virtual Annual Wellness Visit
While many patients are delaying care due to the pandemic, it is important to remember that you can still provide services to your patients virtually using telehealth. Clinicians can conduct a Medicare Annual Wellness Visit (AWV) with established patients using telehealth, as long as an in-person “Welcome to Medicare” visit has already been completed for these patients. AWVs can play an important role in keeping your patients healthy and out of the hospital during the COVID-19 pandemic. It is also a chance to check in with your patients and see how they are coping during the pandemic and addressing any behavioral health concerns.
Here are some tips to keep in mind when arranging an AWV over telehealth:
- As with other telehealth services, you are required to obtain and document your patient’s consent for a virtual AWV.
- AWVs can be conducted using approved telehealth technologies, including non-HIPAA compliant technologies such as Apple FaceTime, Skype, or Google Hangout. AWVs can also be completed using audio-only telephone visits if a video platform is not available to the patient.
- Providers can use the G0438 billing code for an initial AWV or the G0439 billing code for subsequent AWVs.
- AWV claims should be billed with the Place of Service (POS) code that describes where the visit would have occurred if there was not a public health emergency.
- During these visits, patients can self-report vital signs, such as weight, height, and blood pressure. More guidance is expected to be released from CMS on how to document vital signs that cannot be self-reported.
For more resources on conducting an AWV, check out Alliant’s Annual Wellness Visit Workflow or the CMS Medicare Learning Network (MNL) booklet. For assistance adapting the AWV to telehealth, reach out to your Technical Assistance Contractor. To find your Technical Assistance Contractor, click here.
How to Engage Specialists in MIPS
Each year, MIPS-eligible clinicians should reassess which MIPS quality measures will work best for their practice to achieve the highest possible MIPS score. Solo and small group specialty practices can sometimes struggle to find MIPS quality measures and improvement activities that are relevant to their practice.
The QPP Resource Library has numerous documents that highlight measures and activities that apply to certain specialties. When reviewing the documents below, keep in mind your practice’s data submission type, practice size, and patient demographics. The following documents highlight MIPS measures and activities that apply to the following specialists: Family Medicine Clinicians, Gastroenterologists, Anesthesiologists, Certified Registered Nurse Anesthetists, Dermatologists, Cardiologists, Chiropractors, Clinical Psychologists, Dentists, Dietitians, Nutrition Professionals, Emergency Medicine Clinicians, Nurse Practitioners, Physical Therapists, Occupational Therapists, Obstetricians and Gynecologists, Ophthalmologists, Optometrists, Orthopedists, Pathologists, Physician Assistants, Podiatrists, Radiologists, Speech Language Pathologists, Audiologists.
Reminder: Check out your Technical Assistance Contractor specialty resources
Many Technical Assistance Contractors have created their own specialty guides or tip sheets to help specialists identify relevant MIPS measures, including Comagine, NRHI, and Telligen. Altarum created a series of 2020 MIPS Tips for Small Specialty Practices with lists of relevant quality measures and improvement activities for each specialty by name and ID number, as well as links to the Measure Specification sheet, measure weighting, and the measure reporting process. Clinicians are instructed to choose six quality measures, including one outcome measure, if available, or one high-weighted measure. Quality measures can be reported by claims, registry, or EHR.
For example, mental and behavioral health practices can report key quality measures, including:
- Closing the Referral Loop: Receipt of Specialist Report (ID Number: 374) – High weighted, intermediate outcome measure reported by EHR or Registry
- Adherence to Antipsychotic Medications For Individuals with Schizophrenia (ID Number: 383) – High weighted measure reported by Registry only
- Adult Major Depressive Disorder (MDD): Suicide Risk Assessment (ID Number: 107) – Medium weighted measure reported by EHR only
- Anti-Depressant Medication Management (ID Number: 009) – Medium weighted measure reported by EHR only
- Closing the Referral Loop: Receipt of Specialist Report (ID Number: 374) – High weighted measure reported by EHR or Registry
- Continuity of Pharmacotherapy for Opioid Use Disorder (OUD) (ID Number: 468) – High weighted measure reported by Registry
Techinical Assistance Contractors also provide lists of improvement activities by specialty. Providers should choose one high-weighted or two medium-weighted Improvement activities. For example, an oncology practice can select a high-weighted improvement activity such as:
- Collection and follow-up on patient experience and satisfaction data on beneficiary engagement (ID Number: IA_BE_6)
Monthly Observance – National Immunization Awareness Month
August is National Immunization Awareness Month in the United States, an opportunity to remind your patients of the vital importance of immunization for people of all ages.
According to the Centers for Disease Control and Prevention (CDC), stay-at-home and shelter-in-place orders have resulted in fewer outpatient visits and fewer vaccines being administered since the beginning of the COVID-19 pandemic. Keeping your immunizations current is especially important this year, to reduce the risk of illness and the need for health care.
To help promote widespread vaccination in honor of the Awareness Month, the CDC has released a series of guides to help providers talk to their patients and other healthcare professionals about vaccinations.
MIPS also includes several quality measures related to immunization. Read more about these measures below and consider including them in your reporting to improve care and strengthen your MIPS score:
- Preventive Care and Screening: Influenza Immunization (Quality ID 110): Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization.
- Pneumococcal Vaccination Status for Older Adults (Quality ID 111): Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine.
For more information on these and other MIPS measures, check out the Explore Measures and Activities tool on the QPP website.