Month: November 2013

Learn How to Avoid the 2015 PQRS Payment Adjustment

Providers considered eligible and able to participate in the Physician Quality Reporting System (PQRS) may be subject to payment adjustments beginning in 2015. Eligible professionals (EPs) and group practices that fail to satisfactorily report data on quality measures during the 2013 program year will be subject to a 1.5% payment adjustment of their Physician Fee Schedule (PFS) charges beginning in 2015.
Individuals and group practices participating in PQRS must meet one of the following criteria to avoid payment adjustments in 2015.

Criteria for Individual EPs

EPs can avoid the 2015 payment adjustment if one of the following criteria is met during the 2013 PQRS program year:
1. Meet the requirements outlined in the 2013 PQRS measure specifications* (this will enable the EP to earn a 2013 PQRS incentive payment of 0.5% of their covered Medicare Part B charges)
2. Report at least:
One valid measure via claims, participating registry, or through a qualified Electronic Health Record (EHR) OR
One valid measures group via claims or participating registry
3. Elected to participate in the administrative claims-based reporting mechanism October 18, 2013

Criteria for Registered Groups (ACO/PQRS GPRO)

Group practices participating in the Group Practice Reporting Option (GPRO) can avoid 2015 payment adjustments if one of the following criteria is met during the 2013 PQRS program year:
1. Group meets the following requirements, outlined in the 2013 PQRS GPRO Fact Sheet
Report specific ACO/GPRO measures through the Web Interface OR
Report at least 3 registry measures (for 80% of the group’s eligible patients for each measure) for the GPRO outlined in the 2013 PQRS Measure Specification for Claims/Registry Reporting of Individual Measures
2. Report at least one valid measure through the Web Interface OR participating registry
3. Elected to participate as a GPRO in the administrative claims-based reporting mechanism by October 18, 2013

Note: Administrative claims-based reporting is not available to ACO GPROs

Resources
View the PQRS Payment Adjustments Tip Sheet for more information on how to avoid the 2015 payment adjustment.
For more information or support on the PQRS program, please visit the PQRS Incentive Program website or the Help Desk.
*Note: The asterisk indicates resources are in a zip file.

ICD-10 Walking Through the Workflow

With less than a year to go until the ICD-10 code set implementation deadline, physician practices should be pursuing a comprehensive plan designed to ensure a smooth coding transition with minimal cash flow disruption.

A key step in any ICD-10-CM transition strategy is to conduct a detailed assessment of existing workflows and processes to determine which elements will require modification, according to Bess Ann Bredemeyer, a consulting director with McKesson Business Performance Services (BPS).

By identifying each point in the claims lifecycle that ICD-10- CM will touch, appropriate adjustments can be made and simulations conducted to test the new processes against real-world conditions.

“The best way to proceed with an assessment is to begin at the patient encounter and then move through to the claim drop and denial management,” Bredemeyer said. “That way you won’t miss anything.”

Clinical Documentation  Whether the clinical documentation is sent directly to a coder or to data entry personnel, it is also important to ensure that any changes in National Coverage Determinations (NCDs) and payer’s Local Carrier Determinations (LCDs) are incorporated and reflected in the claim. A good approach includes:

  • Identifying the top 50 most utilized diagnoses codes
  • Evaluating where additional documentation will be required
  • Mapping out modifications to support appropriate reimbursement
  • Updating charge tickets, super-bills and other revenue cycle tools

This is a Test  With all the elements theoretically in place, it is critical to begin testing your new workflow to determine if it can handle ICD-10-CM. Code audits can assess both clinical documentation and coding to determine whether the claims should come through clean or not. A real-world testing process may also reveal previously unknown problems that would otherwise remain hidden until the ICD-10 go-live.

Don’t Be Denied  Because of the complexity of ICD-10-CM and the sheer magnitude of the change, it’s reasonable to assume that even the best-laid plans may encounter some unexpected problems. For that reason, it makes sense to be prepared for a rise in denials. For physician practices, that means ensuring that staffing is adequate to manage an increase in volume, and that problems will be quickly identified and remediated.

“There is no denying that the transition to the new code set will require planning and resources to mitigate the burden of change,” Bredemeyer said. “That’s why you should get started now on developing a workflow analysis impact assessment that will help you develop a detailed ICD-10 timeline and budget.”

Article Resource:

ReveNEWS, Industry Spotlight, “Walking Through the Workflow- An Important First Step,” November 2013 edition located on the McKesson ReveNEWS website

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