03/04/2019

ASK MSHO

March 2019, Frequently Asked Questions

Question: For our services in 2019, how many MIPS points do we need to have to avoid a negative adjustment and how bad can the adjustment be?
 
Answer: You need at least 30 points in your MIPS Final Score for 2019 Performance year to avoid a negative adjustment in your 2021 Medicare payments.
2021 payment adjustments will be between -7% to +7% based on 2019 Performance Year
0-7.5 points in MIPS Final Score guarantees -7% adjustment.

Question: Can you confirm the MIPS Scoring Categories for 2019 services?
 
Answer: A clinician’s annual MIPS score of up to 100 points is determined by four categories of clinician performance and bonus point opportunities. See below for the 2019 performance year, and associated 2021 payment adjustment year:
·     Quality 45% weight, or 45 MIPS points maximum
·     Cost 15% weight, or 15 MIPS points maximum
·     Promoting Interoperability (PI) 25% weight, or 25 MIPS points maximum
·     Improvement Activities (IA) 15% weight, or 15 MIPS points maximum
·     Complex Patient Bonus 5 MIPS points maximum
 
Should the total points earned be greater than 100 points, a 100-point cap would be applied. Under certain conditions, a clinician may be exempt from a performance category, which then triggers the available points from that category to be reallocated to one or more of the other categories. Note that re-weighting of categories occurs under these circumstances.

Question: When reporting for MIPS, what is considered a “Small Practice” and I hear there is a point bonus for them, is this correct?
 
Answer: Small Practices (15 or fewer in the TIN) will continue to receive a small practice bonus in 2019, but it will be included in the Quality performance category score instead of as a stand alone bonus in 2019. The bonus is also increased to 6 points (up from 5 points in 2018) if the clinician submits data on at least 1 Quality measure. Small practices will also continue to receive at least 3 points for quality measures that do not meet the data completeness requirements.

Question:  When an item or service is not considered reasonable and necessary under Medicare Program standards which modifier needs to be appended?

Answer:  Modifier GA. The definition of GA modifier is, waiver of liability statement issued as required by payer policy. 

You must issue the ABN when: You believe Medicare may not pay for an item or service; Medicare usually covers the item or service; and Medicare may not consider the item or service medically reasonable and necessary for this patient in this particular instance.

Question:  Which modifier is used for statutorily excluded items from Medicare coverage?

Answer:  Modifier GY. Item or service statutorily excluded, does not meet the definition of any Medicare benefit; use this modifier to report that Medicare statutorily excludes the item or service or the item or service does not meet the definition of any Medicare benefit.

Question:  What were the E & M changes that took place this year?

Answer:  For 2019 and beyond, CMS is finalizing the following policies:

• Elimination of the requirement to document the medical necessity of a home visit in lieu of an office visit;
• For established patient office/outpatient visits, when relevant information is already contained in the medical record, practitioners  may choose to focus their documentation on what has changed  since the last visit, or on pertinent items that have not changed, and need not re-record the defined list of required elements if there is evidence that the practitioner reviewed the previous information and updated it as needed. Practitioners should still review prior data, update as necessary, and indicate in the medical record that they have done so;
• For E/M office/outpatient visits, for new and established patients for visits, practitioners need not reenter in the medical record information on the patient’s chief complaint and history that has already been entered by ancillary staff or the beneficiary. The practitioner may simply indicate in the medical record that he or she reviewed and verified this information;
• Removal of potentially duplicative requirements for notations in medical records that may have previously been included in the medical records by residents or other members of the medical team for E/M visits furnished by teaching physicians.

Question:  What are the criteria requirements for incident-provision drugs?  Does the doctor have to be present in the suite?

Answer:  Yes, the physician must be present in the suite.  CMS states, in order to meet all the general requirements for coverage under the incident-to provision, an FDA approved drug or biological must be:

• A form that is not usually self-administered
• Furnished by a physician
• Administered by the physician or by auxiliary personnel employed by the physician and under the physician’s personal supervision.