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Clinical Documentation Improvement (CDI): Initiating a Program for Your Practice

Source: Emily Hill, PA, AAPM Coding Consultant
Date: July 11, 2018

CDI has been described as the process of improving healthcare records to ensure improved patient outcomes, data quality, and accurate reimbursement. Historically this has been a hospital-based program that may have important applications to physician practices. Last month, we reviewed the basics of CDI. It is now time to consider the steps of incorporating this into your office-based practice.

As with other types of initiatives, the first step is to assess your current situation. A logical first step for a CDI program is to conduct a base-line audit of your medical record documentation to identify areas that may require improvement or corrections. Most medical record audits focus on accurate CPT and ICD coding which is an important first step in a CDI focused audit as well. Improved reimbursement and reduction in audit liability are some of the goals of a CDI program.

A CDI audit may also investigate documentation processes that impact the quality of the medical record such as the benefits and distractions of drop-down lists, check boxes, macros, and templates. It may also look for redundant documentation and processes that impede the efficiency of the physicians and the clinical effectiveness of the documentation. A review of denials for systemic or provider specific issues is another effective tool for identifying areas that need to be addressed.

An effective program cannot be implemented without staff and physicians who are open and involved in the process. The degree of expertise and readiness of staff to participate in CDI and the understanding and degree of support of the physicians is a critical component of a CDI program.

The steps above provide the beginning of your CDI program. In future newsletters, we’ll look at the next steps for implementing your program including identifying your CDI team. Remember that good documentation is an important step in providing quality patient care and ensuring appropriate reimbursement for your practice.


CMS Releases Proposed Rule for 2019

Source: Emily Hill, PA, AAPM Coding Consultant
Date: July 23, 2018

On July 12, 2018, the Centers for Medicare and Medicaid Services (CMS) released the 2019 Medicare Physician Fee Schedule (PFS) and Quality Payment Program (QPP) Proposed Rule. This is the first time that CMS has combined the two programs into a single proposed rule. CMS is requesting comments on the proposed rule by September 10, 2018, and a final rule is expected to be released in November.

The proposed conversion factor for 2019 is $36.0463. This reflects a statutory update of .25%, offset by a budget neutrality adjustment of -0.12 percent, resulting in a 0.13 percent update. The conversion factor is multiplied by the total adjusted Relative Value Units (RVUs) to achieve a payment amount for the services included in the Medicare Physician Fee Schedule.

The Proposed Rule also provides an update to the global surgical data collection intended to assess the accuracy of global surgical package valuation. The data collection was mandated as part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and was initiated in July 2017. Groups of 10 or more practitioners in 9 nine states were required to use CPT code 99024 to report postoperative visits for selected procedures. Only 45% of practitioners that met the criteria for reporting participated. Of those “robust participators”, only 16% of the 10-day global services and 87 % of 90-day global services had one or more matched visits reported. In the Proposed Rule, CMS is seeking comments on ways to increase participation in the data collection and also if visits are typically being performed in the 10-day global period.

Perhaps receiving the most attention, are coding and payment proposals for Evaluation and Management Services (E/M). CMS is proposing new, single blended payment rates for new and established patients for office/outpatient E/M level 2 through 5 visits. A series of add-on codes would be available for select specialties, primary care and for prolonged E/M services. In conjunction, they are proposing that codes be selected based on medical decision-making alone or face-to-face time with the patient rather than the current 1995 or 1997 Documentation Guidelines. Providers who choose to continue using the Documentation Guidelines would need to meet the minimum documentation standards for a level 2 E/M service. CMS is also proposing other documentation changes designed to reduce the documentation burden on physicians. CMS is seeking comments on other documentation systems and the relationship to Electronic Health Records as well as how documentation guidelines for the medical decision-making component might be changed. The proposed blended payment rate for established patient E/M services 2-5 is $92 and for new patient encounters levels 2-5 the rate is $134.

In addition to the changes in documentation and payment rates, CMS is also proposing a multiple service reduction of 50% for the least expensive procedure or visit that the same physician (or a physician in the same group practice) furnishes on the same day as a separately identifiable E/M visit.

The Proposed Rule also addresses the valuation of specific services as well as the processes for determining the practice expense and malpractice RVUs assigned to services. The AMA and specialty societies, including AAPM, are in the process of reviewing these and other proposals.

CMS has published several fact sheets on the rule including a fact sheet on the PFS proposals for 2019. The entire Rule can be accessed at: Revisions to Payment Policies under Physician Fee Schedule and Other Revisions to Part B for CY 2019; Medicare Shared Savings Program Requirements.

The proposed changes to the Quality Payment Program will be addressed in the next e-news.

Highlights of the CMS Proposed Rule for the Quality Payment Program

Source: Emily Hill, PA, AAPM Coding Consultant
Date: August 8, 2018

The CMS Proposed Rule for the Quality Payment Program (QPP) addressed several key changes to the 2019 QPP. The Rule expands the definition of MIPS (Merit-Based Incentive Payment System) eligible clinicians to include physical therapists, occupational therapists, clinical social workers, and clinical psychologists and provides additional flexibilities for small physician practices.

It also adds an additional element for providers to quality for the low volume threshold and thus opt-out of the MIPS program. For 2019 a clinician must meet one of the following criteria:

  • ≤ $90,000 of Part B allowable charges
  • ≤ 200 Medicare beneficiaries
  • ≤ 200 Covered Professional Services

CMS also provides an “opt-in” option for those clinicians who meet or exceed one or two, but not all, of the low-volume threshold criteria. CMS also proposes to remove Part B drugs from the low-volume threshold determinations and from physicians’ payment adjustments.

CMS continues its Meaningful Measures Initiative by adding and removing a number of current quality measures. It also proposes to revise the definition of a high-priority measure to include quality measures that relate to opioids and to further clarify the types of outcome measures that are considered high priority. Quality now makes up 45% of a physician’s MIPS score.

For 2018, 10% of physicians MIPS score is tied to costs. This was to increase to 30% for 2019. Legislation passed earlier this year and supported by the AMA authorized CMS to weight costs at any level from 10% to 30% through the next three years. CMS is proposing to increase the cost weight to 15%in 2019 and then increase it by an additional 5% in each of the next two performance years until it reaches the maximum 30% in the 2022 performance year.

Advancing Care Information has been renamed to Promoting Interoperability (PI) and composes 25% of the MIPS score. The proposal requires physicians to use 2015 Certified Electronic Health Record Technology (CEHRT) and proposes a new scoring methodology. It also adds two new measures to the e-Prescribing objective: Query of Prescription Drug Monitoring Program and Verify Opioid Treatment Agreement.

Changes are also proposed to the Improvement Activities (IA) component which comprises 15% of a physician’s score. CMS proposes to maintain an attestation reporting option and a 90-day reporting period for the IA performance category. CMS is proposing 6 new IAs, modifications to 5 existing IAs, and removal of 1 existing IA.

View the CMS Fact Sheet on the MIPS Proposed Rule

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