FEATURE
level two through level five visits for a single reimbursement based
upon median cost paid per visit. However, with the response CMS
received the plan has been modified. For Calendar Year (CY) 2019
and CY 2020, the existing E/M codes should be submitted as before.
The most important part of the documentation requirement is that
if “relevant information” on the patient is in the record, it does not
have to be documented again. Instead the physician’s documenta-
tion should focus what has changed since the last visit, the current
assessment and the treatment plans. Electronic medical records
(EHR) will require a radio button to be checked that the physician
has reviewed the previous information. Until that is included in a
doctor’s EHR, the physician will need to note that prior records
have been reviewed. By the same token, if the medical assistant
has included pertinent information, the physician needs only to
document that (s)he has reviewed that part of the record and will
not have to duplicate the finding.
and clinical outcome markers.
• Resource use is a measure of quality. Measurement of unplanned
re-admission rates has significant cost implications. Before CMS
began looking at re-admissions as a marker of the quality of care
planning, more than 22 percent of Medicare hospitalizations
resulted in a re-admission. But since the incentive/penalty
programs were implemented that percentage as dropped to 15
percent. Nationally the re-admission rate among commercially
insured people is roughly half of that at 8.8 percent. In a like
fashion, the End Stage Renal Disease (ESRD) quality program
is really a cost-reduction program based upon adherence of
standard protocols.
• The second type of quality measure is based more upon out-
comes or process measures. While there are cost implications,
the greater utility is in comparison of clinical outcomes. Mea-
surement of HbA1c is an intermediate outcome measure. There
is no immediate cost implication to getting the HbA1c below
seven percent, but there is a strong association of elevated
HbA1c and future complications. So the typical quality mea-
sures used by Medicare and commercial insurers for the last
decade have more to do with evidence and consensus based
standards of quality than cost impact. On a positive note for
physicians, there is a current trend to reduce the number of
measures that physicians are judged on. CMS along with Ameri-
ca’s Health Insurance Plans (AHIP) and major specialty societies
have been working to reduce the number of quality measures
to ones of greater importance. The Core Quality Measures
Collaborative (CQMC) brings clinical perspective along with
input from Medicare and commercial payers to define metrics
that should be the standards used by both government and
commercial payers. The current core measures are in:
Beginning in 2021, CMS is planning to move toward the collapse
of a payment differential for E/M codes level two through level four
for outpatient services. Documentation will need to be available
for these codes at the current level two history, physical exam and
medical decision-making. By 2021, CMS will have a modifier code
when there is a reason for an extended visit. The level five code will
persist for the highest-level evaluations. The goal CMS has is to
allow the physician with a follow up visit to focus on the patient,
and not on the nuances of coding.
USE OF TECHNOLOGIES:
CMS believes that the use of telecommunications will improve
patient access and lower the unit cost of visits. New HCPCS codes
have been developed for “brief communication technology-based
services” such as virtual visits (G2012) and evaluation of remote
recorded videos or images for established patients (G2010). Tele-
medicine will be covered in July of this year for opioid use disorders
under a provision in the Patients and Communities Act, “Substance
Use-Disorder Prevention that Promotes Opioid Recovery and Treat-
ment,” (SUPPORT).
» » Accountable Care Organizations (ACOs), Patient Centered
Medical Homes (PCMH), and Primary Care
» » Cardiology
» » Gastroenterology
NON-PHYSICIAN HEALTH CARE PROVIDERS: » » HIV and Hepatitis C
CMS believes that comparable services by non-physicians can
reduce health care costs. CMS is looking to create more access and
include other incentives for use of non-physician providers. Start-
ing this year, the Merit-Based Incentive Payment System (MIPS)
will include as eligible clinicians physical therapists, occupational
therapists, speech therapists, audiologists, clinical psychologists and
registered dietitians. By including them in MIPS, the hope is that
services will be referred to these lower costs providers rather than
to more expensive specialists. All low volume clinicians, including
these new non-physician providers, may opt-in to MIPS. » » Medical Oncology
» » Obstetrics and Gynecology
» » Orthopedics
» » Pediatrics
QUALITY:
The metrics for quality used by CMS come from both resource use
•
The third type of quality judgment comes from Consumer-
Assessment of Healthcare Providers and Systems (CAHPS)
which is based upon patient views of the quality of care, the
experience in the physician office, and patient recollection of
health care services provided (e.g. flu shots). This reliance on
patient experience now has spilled over to the Medicare cov-
erage of services. In August 2018, the Medicare Evidence and
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FEBRUARY 2019
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