Category Archives: Uncategorized

Low-volume Threshold: MIPS 2018

The Centers for Medicare and Medicaid Services (CMS) are beginning to recognize that solo and small practices are having difficulty meeting the requirements of the Merit-Based Incentive Payment System (MIPS).  As a result, they have expanded the low-volume threshold in 2018 (APAPO, 2017).  This is good news for psychologists because many of us will fall under the low volume threshold and not be required to report under MIPS.

In 2018, a psychologist will not have to report under MIPS if he/she treats 200 or fewer Medicare Part B beneficiaries or bills Medicare Part B for $90,000 or less in allowable charges.   This is 200 or fewer unique patients, not sessions.  Revenue from Medigap policies (secondary payers) or Medicare Advantage plans is not included in the $90,000 figure.  Thus, only revenue directly from Medicare Part B reimbursement is counted.  Also, patient’s that have Medicare Advantage plans are not included in the patient count. This means that if you saw 201 or more patients, but received less than $90,000, you still would not have to report.  Likewise, if revenue was over $90,000, but you saw 200 or fewer unique Medicare Part B patients, you would not have to report.

If you are in solo practice, it is very straight forward: you simply count your Medicare Part B patients and tally your Medicare Part B revenue.  If you are in a group practice, you may or may not have to report MIPS depending on how you are categorized (billed).

If you are categorized as being in a group practice it is not so clear.  If billing is done using your own NPI number but the group’s Tax ID number, then the cumulative Medicare Part B reimbursement of all members of the group practice might count toward the low volume threshold.  In this case, if revenue was over $90,000 (and 201 or more unique individual patients were seen) all members would be required to report under MIPS.

For further clarification and with the help of Diane Pedulla we asked CMS how an individual psychologist would be categorized (i.e., as an individual provider within a group or as part of a group) when using a billing service that uses the same Tax ID number for all the providers that are billed through that service.  We have not yet received a response but will update you as this information becomes available.

So,  currently it isn’t entirely clear how CMS tracks whether you are part of a group or an individual within a group, especially if you are an independent contractor (personal communication with Diane Pedulla, 2018).   You may very well be able to determine for yourself how you want to categorize yourself.  The obvious benefit of falling under the low volume threshold is that you don’t have to worry about MIPS and you will not receive a payment penalty.  However, you will also not be eligible for a payment bonus.  The penalty/bonus is expected to reach +/-9% in 2022.

Many psychologists will elect to participate in MIPS to benefit from a payment bonus, even if they fall under the low volume threshold.   Psychologists have been exempt from MIPS in the first two years of the program.  In 2019, we will be required to participate in MIPS if we don’t fall under the low volume threshold. Participation in 2019 will make us eligible for a payment penalty or bonus in 2021.

Always keep in mind that CMS may change the low volume threshold and/or any other aspect of the MIPS program on a yearly basis.

In the next blog, I will begin to address the various aspects of MIPS reporting.

 

Dori Ann Bischmann, PhD

Clinical psychologist

Federal Advocacy Coordinator for APA

 

APAPO (11/30/2017).  Low-volume threshold expanded in 2018 Quality Payment Program Rule. http://www.apapracticecentral.org/update/2017/11-30/low-volume-threshold.aspx.

Pedulla, D. (2018).  APAPO Government relations staff. Personal communication regarding MIPS.

 

 

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Measure #317: Preventive care and screeing: Screening for High blood pressure and follow-up

High blood pressure screen #317

2015 reporting options:  Claims and registry

Patient age:  18 and up

Diagnosis Code:  No specific diagnosis is associated with this measure.  Measure not appropriate for patients who already have an active diagnosis of hypertension.

CPT codes:  90791, 90832, 90834, 90837, 96118

Reporting requirements:  1. Report once per reporting period (calendar year). 2. Measure blood pressure during the qualifying session.  You can not obtain the measurement from an outside source (such as the medical record).  My interpretation of this is that you must do the blood pressure reading yourself or you could have an aid/nurse do the reading in your presence.    3. If BP falls in the pre-hypertensive or hypertensive range, document a follow-up plan (see CMS for recommendations on possible follow-up plans). 

Blood pressure parameters:

Prehypertensive:  greater than 120/80 but less than 139/89

Hypertensive:  greater than 140/90 

Please see CMS.GOV, 2015 measures list for additional details about this measure.

Resources:

CMS.GOV (12/23/14).  2015 measures list, Measure #317 Preventive Care and Screening:  Screening fo High Blood Pressure and Follow-up Documented_National Quality Strategy Domain: Community/Population Health   

Blog Author:  Dori Ann Bischmann, PhD

WPA Advocacy Cabinet

PQRS Measure #128: preventive Care and Screening: Body Mass Index (BMI) screening and Follow-up Plan

BMI measure #128

2015 reporting options:  Claims and registry

Patient age:  18 and up

Diagnosis Code:  No specific diagnosis is associated with this measure.

CPT codes:  90791, 90832, 90834, 90837, 96150, 96151, 96152

Reporting requirements:  1. Report once per reporting period (calender year). 2. Measure height and weight (information can be gathered from outside source such as the physician’s office or via another provider in facility, i.e. dietician) and calculate the BMI.  Self-reported values, from the patient, cannot be used.  The BMI data used should be no older than 6 months.  Use a BMI chart to determine the BMI from height and weight data. Many different BMI charts are available, in the public domain, via the internet.  Normal BMI parameters are as follows: 

Age 65 years and older; BMI greater than 23 and less than 30 kg/m. 

Age 18-64; BMI greater than 18.5 and less than 25 kg/m. 

 3. If the BMI is outside normal parameters, establish a follow-up plan.  The follow-up plan may include a referral to another provider (e.g. dietician, physician), education or specific psychological goals to address weight. 4. Document BMI and follow-up plan in medical record.   

SIDE NOTE: While we are not supposed to use self-reported values, it is my opinion that I will use self-reported values on occasion.  In my facilities, I can gather the information from the dietician’s notes.  In my outpatient office, I can weigh and measure the patient with the available scale.  However, in the office and when I do home visits I may have to rely on the patient’s report, if I am unable to get data from a physician’s office.  It is my opinion that it is better to complete the measure, using the patient’s self reported data, than to skip the measure or put the patient in danger (I work with disabled patients who may or may not be able to safely get on a scale.  I will not take that risk, even in the office where a scale is available.)  Furthermore, height information gathered from outside sources may be based upon the patient’s self report.  I have talked to dietician’s in hospitals where I work.  They typically ask the patient for their height.  They don’t measure the pt directly unless they are ambulatory (usually outpatients) or comatose (wherein the patient can not report a height. The dietician measures the patient from the sternum to the tip of his/her fingers and then doubles that for a measure of the patient’s height).    

Please see CMS.GOV, 2015 measures list for additional details about this measure.

Resources:

CMS.GOV (12/23/14).  2015 measures list, Measure #128 (NQF 0421):  Preventive care and screening:  body mass index (BMI) screening and follow-up plan-National Quality Strategy Domain:  Community/Population Health.   

Blog Author:  Dori Ann Bischmann, PhD

WPA Advocacy Cabinet

Dori’s PQRS Picks for 2015

In 2015, I will again report via registry.  So my requirements for picking measures include:  measures that are appropriate for psychologists, measures that are appropriate for my client mix and measures that are available via registry.

All of the claims-based measures are available for registry reporting, so those of you who are reporting via claims can utilize the first section of my picks.  This year there are only 6 (there actually appear to be 7*) measures available for claims-based reporting that are appropriate for psychologists (APAPO, 1/25/15).  You must report on as many of these measures as are appropriate to your patient population to meet Medicare’s criteria for successful PQRS reporting.  Obviously, if you do not work with individual’s over age 65, you would not report on measure # 181, elder maltreatment screen and follow-up plan.  But if you have even one client over age 65 (who is a Medicare FFS recipient),  you must report on measure #181.  The remaining 5 measures are appropriate for every psychological practice. 

Recall that Medicare requires that providers report on 9 measures over the 3 NQS domains on 50% of eligible FFS Medicare recipients.  Since 9 measures aren’t available to psychologists via claims, you will need to report on all 6 available (or 5 if no patients over age 65) measures and will be reviewed via the MAV system (see previous post for description of MAV).  

The 7 measures available for claims based and registry reporting include:

#128 body mass index,

#130 documentation and verification of current medications in the medical record,

#131 pain assessment prior to initiation of patient treatment,

#134 screening for clinical depression, (note that the age for this measure is 12 yrs and up) 

#181 elder maltreatment screen and follow-up plan

#226 preventive care and screening:  tobacco use-screening and cessation intervention

#317 preventive care and screening: screening for high blood pressure and follow-up

Since I will be reporting via registry, I will also be using 3 additional measures to bring my total measures count to 9.   Note that there is an additional measure and measure group that could be used if reporting via registry.  I have chosen not to use those two options because they do not fit my patient population.

The three registry only measures I will be using are:

#173 unhealthy alcohol use

#325 adult major depressive disorder (MDD); coordination of care of patients with specific comorbid conditions

#383 adherence to antipsychotic medications for individuals with schizophrenia.

For additional details about PQRS and these measures, see previous posts.  I will be outlining some of the new measures in subsequent posts.

*Measure #317: Preventive care and screening:  screening for high blood pressure and follow-up appears to be appropriate for psychologists to report.  APA did not include this measure in it’s list, but it does include our CPT codes

Resources:

http://www.apapracticecentral.org

CMS.gov (12/23/14).  PQRS, 2015 measures list.

Blog Author:  Dori Ann Bischmann, PhD

WPA Advocacy Cabinet

 

 

Advocacy and the Internship Shortage

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Once again, our psychology doctoral students are facing a serious shortage of internship slots. This year, 4051 students submitted a ranking list for the match. However, only 2,515 positions were available at APA- and CPA-accredited internship sites, and another 861 positions were available at APPIC member, non-APA/CPA-accredited internship sites. This means that at least 675 students will not be placed.  In fact, after the 1st match, 60%  matched to APA- and CPA-accredited internship sites and another 16.4%  matched to APPIC member, non-APA/CPA-accredited internship sites. This left 23.6%  (or 957 students) without a match.  This is not a new issue. In 2012, of the 4,067 students participating in the match, 1,041 students did not get any internship match, over 25%.

In addition to this serious pothole in the road to a student’s professional training, the failure to match presents a financial dilemma. Grad students must maintain an active enrollment status, otherwise they must begin to repay their student loans. Since they have not yet completed training, much less achieved licensure, this is not a good place to be.  But, to maintain enrollment means paying for additional credits and adding to their already huge student loan debt.

At the State Leadership Conference in Washington D.C. this past March, I attended a meeting intended to discuss this issue.  It was heavily attended by grad students, but attended very lightly by APA leadership. The students (very respectfully and politely) asked some disturbing questions:

1)      While the opening addresses of the conference referred to grad students as the “lifeblood” of APA, why was the internship shortage not identified as a key initiative?

2)      While APA leadership has noted that the shortage has been a worsening issue for as long as 20 years, why has APA only recently begun to take action?

To give APA credit, they are taking some actions.

1)      APA has developed a group, headed by Dr. Sharon Berry (former director of APPIC) to work on identifying and make recommendations for addressing the many issues that contribute to the shortage.  In particular they seem interested in the development of new sites.

2)      The Internship Stimulus Package 2012 has been allocated  $3 million over 3 years. It has already funded the development of  32 sites, at an average of $20,000 each.

3)      The Committee on Accreditation has completed work on streamlining the accreditation process, such that programs can achieve accreditation more quickly.

In Wisconsin, we are in the process of forming our own work group to address the shortage of sites.  Presently, there are 6 APA accredited internship sites in Wisconsin (site visits in parentheses):

ž     Aurora Behavioral Health – Wauwatosa (inactive)

ž     Lincoln Hills School (2013 site visit)

ž     Mendota MHI (2018)

ž     Milwaukee VA (2015)

ž     Wisconsin DOC (2013)

ž     UW Center for Health Sciences (2013)

ž     UW Counseling and Consultation Services (2018)

Our preliminary inquiries so far have suggested that the difficulty in developing and maintaining a site is, like everything else, “about the money”.  The development of a site requires a great deal of staff time to address all of the APA requirements.  More staff time is required to provide clinical supervision as well as to provide the required didactic activities. In the “old days”, the cost of this staff time could be offset somewhat with revenue generated by the services provided by interns.  However, other than interns who have their LPC, organizations generally cannot bill for the services of an intern. When the cost of stipends, office space, etc. are added to the picture, the cost of an internship can become prohibitive for a private, for profit facility.  (The picture is better for a public facility like the VA or Corrections. Since billing is not as relevant, interns can make up for some of staff service activities.)  However, we have recently learned that, at least in Minnesota, interns and post docs can bill private insurance and Medicaid.  Therefore, there may be Wisconsin regulatory issues that need to be addressed.

Another issue to be investigated is the importance of attending an APA accredited internship vs. one that is approved by APPIC.  Depending on a student’s career plan, it’s not clear if APA accreditation is essential.  For instance, to work at the VA or teach in an APA accredited graduate school, one would need to attend an accredited internship.  But, to work in a private practice, a clinic, even most hospitals, APA accreditation may not matter as much. We will need to gather data on this issue.

In addition to gathering data, and identifying obstacles, the Work Group will work on facilitating the development of coalitions or consortiums that might work to develop new sites.

If you are interested in getting involved with this Work Group, please contact me (Greg Jurenec, gjurenec@wspp.edu) or the Work Group’s point person, Jessie Schroeder (DrJessie.hcllc@gmail.com).

The Advocacy Cabinet

(post author: Greg Jurenec, phD)

Great News: 26.5% SGR Cut is Postponed for Another Year

In a last-minute vote on December 31, 2012, congress voted to postpone the 26.5% SGR (Sustainable Growth Rate) cut through December 31, 2013.  We can breathe a sigh of relief for another year, but we will be facing an SGR cut again.

As many of you know, the Physician’s (includes Psychologists) fee schedule in Medicare is tied to economic markers (SGR).  Over these last 10-12 years, the fee schedule formula has produced cuts to Physician fee’s.  In the earlier years, cuts were approximately 4 to 5%, but as the cuts were postponed, they continued to grow every year.  We have lobbied Congress approximately 15 times in the last 10-12 years to postpone these devastating cuts.  Each year congress responded to grass-roots efforts and postponed the cuts.

At this time, congress only has the power to postpone cuts.  Without a major overhaul to Medicare law, the formula specifying physician fee’s can not be changed.  As you can imagine, changing Medicare law is a huge undertaking.

In concert with many other provider associations, APA is lobbying congress to work on a permanent solution to this ongoing and growing problem.

As psychologists, it is important that we continue to be active at a grass-roots level to advocate for initiatives that improve/maintain the integrity of our profession as well as provide the best opportunities for our clients to access psychological services.

APA makes it simple for us to remain involved via their communication and action alerts notifying psychologists of pertinent issues.  When you see these alerts, it is as simple as clicking a link which will take you to the legislative action center where you can obtain the names of your congressional representatives just by entering your zip code.  A sample letter is available for you to send as is or modify per your desire.  It takes less than 5 minutes to send out these emails and is well worth your time!

Advocacy Cabinet

(post by Dori Bischmann, PhD)