From Paul M. Katz 20161014
MIPS: Where Should our Medical Practice Start?
Start with what you can actually control—improving the use, completeness, and accuracy of diagnosis codes in medical service billing.
MIPS, the CMS Merit-based Incentive Payment System, brings to medical professionals what hospitals already experience with Medicare payments. Quality and the overall cost of care (called “Resource Use”) for your patients are factored into your practice’s Medicare reimbursement. Initially, 60% of the MIPS composite score is composed of quality and resource use measures. The remainder of the composite score relies on physician attestations for EMR use and Clinical Practice Improvement.
Medicare’s underlying assumption is that accurate and complete recording of all relevant diagnosis codes for each patient seen in your practice are included in your billing to CMS. If you are the exceptional practice where coding is always complete and accurate, no need to read further. For everyone else, there is important work to do.
Why Accurate Coding Is Important for Quality Measures
MIPS adopts the Physician Quality Reporting System “PQRS” measures that have been in use since 2008. Measures work by starting with an evaluation of all patients seen by the practice that meet each measure’s denominator criteria. While preventive care measures such as cancer screenings and flu shots include patients based on their age and gender, the majority of MIPS’ Quality Measures use diagnosis codes to identify patients for inclusion, either positively (patient with diabetes, patient with heart failure, patient with coronary artery disease) or negatively (exclude patients with egg allergy from the measure for flu shots or patients allergic to ACE Inhibitor or ARB therapy for the measure for heart failure). The more accurate and complete diagnosis codes are on your submitted medical claims, the more likely the patients selected for the measures are correctly included or appropriately excluded from the MIPS’ Quality Measures.
Resource Use Measures Rely on Consistent Use of Relevant Diagnosis Codes
CMS Resource Use measures generally compare a patient’s actual cost and utilization, either total cost or for a specific type of condition, compared to CMS-calculated benchmarks for that measure, risk adjusted for differences in patient acuity. Risk adjusting considers that some physicians’ practices have sicker patients that appropriately use more resources. CMS utilizes two risk-adjusting methodologies—Hierarchical Condition Categories (HCCs) and CMS Episode Groups, both of which calculate an annual aggregation of all of the diagnosis codes reported in each year for each CMS beneficiary on paid medical claims.
In these risk adjusting methodologies, all pertinent diagnosis codes need to be reported at least every year in order for CMS to accurately use them. A diagnosis code reported in a prior year for even a chronic condition like heart failure does not count unless it is also coded in at least one claim in the current measure year.
Reporting all relevant diagnosis codes on each claim is more vital for the CMS Episode Groups. Episode of Care systems (of which CMS Episode Groups is one) evaluate each patient’s longitudinal claims record for diagnosis and service codes, indicating the start of a clinical episode (e.g., COPD, heart failure, dementia), the continuation of that episode over time, and the conclusion of that episode. If providers fail to report pertinent diagnosis codes during the year, they may be inaccurately shortening the duration of an episode and excluding claims and costs that should be part of the episode in the resulting acuity calculation. This is more complicated for Medicare patients, where patients are often seen and treated for multiple conditions during the same physician encounter.
Getting Patient-Physician Attribution Right Relies on Diagnosis Codes
The same data used for the Quality and Resource Use measures also determine which of the many physicians that a patient sees are to have that patient correctly attributed to them, and for which Quality and Resource Use measures. The attribution process depend on what is reported in all of the claims data. The more complete the data reported, the more likely the attribution will be accurate. Without accurate and complete coding, responsibility for a patient may be wrongly assigned.