12 I Winter 2018 www.anjc.info www.njchiropractors.com I 13 Insurance Update MEDICARE Q&A Legislative Update TECHNIQUE Council S C H O L ARSHIP WI N N E R S MEDICARE Q&A Medicare PQRS/EHR - MIPS: Over the last several years, providers have been subject to potential reimbursement penalties from Medicare through two programs, PQRS and EHR. PQRS was the Physicians Quality Reporting System. This is the system through which you were required to submit certain G codes on each Medicare claim relating to certain measures CMS required based on what type of provider you were. Chiropractors were required to submit on Measure #131 Pain Assessment and Measure #182 Functional Outcome Assessment. The reporting requirement for PQRS began in 2013. The results of each reporting year are assessed two years later in the form of a reduction in the provider’s CMS payments if the provider failed. Hence, the 2013 performance would affect reimbursement in 2015; 2014 reporting year affected 2016’s reim- bursement and so on. The penalty gradually rose to 2 percent, where it remained. EHR stands for Electronic Health Records and refers to the CMS requirement of providers to have attested to meaningful use of a certified EHR system. Following a series of financial incentives to encourage providers to adopt the systems, beginning in 2015 a penalty for not attesting was implemented. The penalty began at 1 percent in 2015 and rose to 3 percent, where it remains. Beginning in 2017, these programs were combined with some new initiatives into what CMS is calling MIPS (Merit-based Incentive Payment System). This is a program housed under a larger system called QPP (Quality Payment Program). Starting in 2017, instead of being penalized for each of these programs individ- ually, providers will be given one score which is composed of their compliance and participation levels in all the combined programs. PQRS counts for 60 percent of the score, EHR (now referred to as Advancing Care Information)comprises 25 percent of the score, and a new category called Clinical Practice Improvement Activities makes up the final 15 percent. Based on your score in relation to all other eligible providers you would receive either a penalty reimbursement reduction or a reim- bursement bonus. The range of penalty/bonus starts at 4 percent but over a 10-year period rises to 9 percent. It is important to remember that there is a two-year gap between reporting and the reimbursement adjustment. The reporting in this new program began in 2017, but those results will affect the 2019 reimbursement. Reporting in 2018 will affect 2020 reimbursement. Remember, your 2018 reimbursement will be affected by whether or not you successfully reported on PQRS and EHR in 2016. 2018 is the final year of these penal- ties from the system prior to MIPS. IMPORTANT NOTE: In order to be eligible for the MIPS program, for penalty or bonuses, a provider had to have seen over 100 unique patients AND had over $30,000 in allowable medical billings for the 2017 reporting year. This threshold has risen to 200 unique patients and $90,000 in allowable medical billings to be eligible for reporting year 2018. If you are under either of those thresholds you are not eligible for this program and hence no longer are required to submit G codes for PQRS or attest to meaningful use of an EHR system. If you are under these thresholds, beginning in 2019 you should simply be receiving the normal CMS fee schedule as your reimbursement. You can, however, voluntarily participate if you wish. For more information on the PQRS G codes see the Medicare/Medicaid page of the Insurance section of the ANJC website www.anjc.info or email me at matt@anjc.info. For more information on QPP or MIPS please visit qpp.cms.gov. SHBP Medicare Advantage: In August of 2016, the State Health Benefits Program’s Plan Design Committee passed a resolution to move the majority of Medicare-eligible retirees to a set of customized Medicare Advantage plans created by Horizon and Aetna for the SHBP. This change took effect January 1, 2017. Prior to this, most retirees had traditional Medicare and a SHBP plan as a secondary. The vast majority of retiree’s secondary plans were either the Horizon NJDirect10 or NJDirect15. These plans were eliminated as an option for secondary coverage for retirees. Anyone who had these plans were automatically moved to a Medicare Advantage plan that supposedly mirrored the same benefits they had prior with the combination of traditional Medicare and the secondary. Approximately 60,000 individuals were subjected to this change. It is important to note that these patients no longer have two plans – traditional Medicare and the Horizon secondary. They have one plan – the Horizon Medicare Advantage NJDirect10 or 15. When these plans were approved, Horizon gave lengthy testimony assuring the Plan Design Committee that ALL the benefits that the patients had under the combination of Medicare and Horizon would be available to them in the Medicare Advantage plan. For chiropractors specifically, this means that the full scope of services should be accepted and reimbursed. You may see that most Medicare Advantage plans restrict chiropractic care to “what Medicare covers.” This is of course spinal manipulation exclusively (98940-98942). These Horizon Medicare Advantage NJDirect plans are custom plans for the SHBP that are supposed to cover all services that were formerly allowed including therapies, modalities, evaluations and extra-spinal manipulation. Since the change went into effect, we have been monitoring claims to ensure this is the case. Early on we saw 98943 being denied and immediately contacted Horizon to address the issue and it was resolved. Recently, we have seen 98943 being denied again. We have raised the issue with Horizon and are awaiting resolution. If you have a patient on the SHBP custom Medicare Advantage plans who is denied therapies, modalities or extra- spinal manipulation, please contact me at matt@anjc.info. By Matt Minnella ANJC Director of Insurance & Regulatory Affairs 2018 Winter INSURANCE UPDATE Q Were there any changes to the Medicare diagnosis list due to the Annual ICD-10 CM Code Updates on Oct. 1, 2017? A  The M48.06 code was deleted due to the Annual Code Update and therefore removed from the Group 5 list of ICD-10 codes in the chiropractic policy. Codes M48.061 - spinal stenosis, lumbar region without neurogenic claudication and M48.062- spinal stenosis, lumbar region with neurogenic claudication were added to the Group 5 list of acceptable diagnoses. Q  With proper documentation, does Medicare consider 12 visits in a month or 12 visits in 30 days as reasonable and necessary? A  Medicare considers 12 chiropractic manipulation treatments per month as reasonable and necessary if the medical record supports the service. Q  If I am exempt from MIPS in 2018, do I have still have to report the G-codes for the Pain assessment and Functional Outcome assessment? A No, if you are exempt from MIPS, you are not required to submit these Quality Measures in 2018. Q Are we required to submit a claim for maintenance care to Medicare? A Yes. Even though the CMT code is not” reimbursable “in this case, it is still a “covered” service.  The Mandatory Claim Submission regulation states, “Section 1848(g)(4) of the Social Security Act requires that you submit claims for all your Medicare patients for services rendered. This requirement applies to all physicians and suppliers who provide covered services to Medicare beneficiaries. Q What is the Medicare Part B deductible for 2018? A For 2018, the deductible is $183.00 By Dr. Richard C. Healy ANJC Medicare Consultant