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Excellence in Optometric Education

Implementing New & Revised ICD-10 Codes . John A. McGreal Jr., O.D. Missouri Eye Associates McGreal Educational Institute. Excellence in Optometric Education. John A. McGreal Jr., O.D. McGreal Educational Institute Missouri Eye Associates 11710 Old Ballas Rd.

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Excellence in Optometric Education

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  1. Implementing New & Revised ICD-10 Codes John A. McGreal Jr., O.D. Missouri Eye Associates McGreal Educational Institute Excellence in Optometric Education

  2. John A. McGreal Jr., O.D. McGreal Educational Institute Missouri Eye Associates • 11710 Old Ballas Rd. • St. Louis, MO. 63141 • 314.569.2020 • 314.569.1596 FAX • mcgrealjohn@gmail.com JAM

  3. 2018 Government Changes • ICD-10 Updates for 2018 • Medicare Legislative & Payment Model Changes • Medicare Updates for 2018 • Quality Program Changes • Electronic Health Record MU Program Changes • Merit Based Incentive Program Changes • OIG Updates • RAC Updates JAM

  4. 2018 Government Changes to Fees • Medicare Deductible – part B is $183 for 2018 • Same as 2017 • Medicare Part B standard monthly premium is $134 • Filers with <$85,000/individual, $170,000/joint income • Medicare Part B monthly premium is $187.50 • Filers with $85,000-107,000/indiv, $170-214,000/joint • Medicare Part B monthly premium is $267.90 • Filers with $107-133,500/indiv, $214-267,000/joint • Social Security Administration announced a COLA of 2 % for 2018 JAM

  5. Medicare To Issue New Cards • MACRA 2015 requires CMS to remove SSNs from all Medicare Cards by April 2019 • New Medicare beneficiary Identifier (MBI) will replace the SSN-based Health Insurance Claim Number (HICN) • Will assign a new MBI • 11 characters in length, only numbers and upper case letters • CMS will Mail new Medicare Cards beginning April 2018 • Will phase in new cards by geographic location • Transition period will allow use of either card to exchange data • Goal – to protect HPI & financial information JAM

  6. New ICD-10 Codes for 2018 • 360 new codes, 226 code description revisions • 34 codes changed from valid to invalid, 122 codes deleted • Validity changes – new codes added, changing previously valid to invalid codes, creating a new subcategory • H54.0 Blindness, both eyes • H54.11 Blindness right, low vision left • H54.12 Blindness left, low vision right • H54.51 Low vision right, normal left • H54.52 Low vision left, normal right JAM

  7. New ICD-10 Codes – 2018 Revised Title • H02.05 Trichiasis w/o entropion • H02.051 Trichiasis w/o entropion, right upper lid • H02.052 Trichiasis w/o entropion, right lower lid • H02.053 Trichiasis w/o entropion, right, unspecified • H02.054 Trichiasis w/o entropion, left upper lid • H02.055 Trichiasis w/o entropion, left, lower lid • H02.056 Trichiasis w/o entropion, left, unspecified • H02.059 Trichiasis w/o entropion, unspec eye, unspec lid JAM

  8. New ICD-10 Codes – 2018 • H44.2A Degenerative myopia (w choroidal neov) • H44.2A1 Degenerative myopia (w choroidal neov) right • H44.2A2 Degenerative myopia (w choroidal neov) left • H44.2A3 Degenerative myopia (w choroidal neov) both • H44.2A9 Degenerative myopia (w choroidal neov) unspec JAM

  9. New ICD-10 Codes – 2018 • H44.2B Degenerative myopia (w macular hole) • H44.2B1 Degenerative myopia (w macular hole) right • H44.2B2 Degenerative myopia (w macular hole) left • H44.2B3 Degenerative myopia (w macular hole) both • H44.2B9 Degenerative myopia (w macular hole) unspec JAM

  10. New ICD-10 Codes – 2018 • H44.2C Degenerative myopia (w RD) • H44.2C1 Degenerative myopia (w RD) right • H44.2C2 Degenerative myopia (w RD) left • H44.2C3 Degenerative myopia (w RD) both • H44.2C9 Degenerative myopia (w RD) unspec JAM

  11. New ICD-10 Codes – 2018 • H44.2D Degenerative myopia (w foveal schisis) • H44.2D1 Degenerative myopia (w foveal schisis) right • H44.2D2 Degenerative myopia (w foveal schisis) left • H44.2D3 Degenerative myopia (w foveal schisis) both • H44.2D9 Degenerative myopia (w foveal schisis) unspec JAM

  12. New ICD-10 Codes – 2018 • H44.2E Degenerative myopia (w other maculopathy) • H44.2E1 Degenerative myopia (w other maculop) right • H44.2E2 Degenerative myopia (w other maculop) left • H44.2E3 Degenerative myopia (w other maculop) both • H44.2E9 Degenerative myopia (w other maculop) unspec JAM

  13. Blindness & Low Vision Codes – 2018 • CMS added over 50 blindness and low vision codes • Allows coding of right and left eyes when different categories of disease exists or • Low vision in one eye and blindness in the other, along with creating new subcategories of each JAM

  14. New ICD-10 Codes – 2018 • H54.- Blindness & low vision • H54.0 Blindness, both • H54.0X Blindness, both, different category levels • H54.0X3 Blindness, right, category 3 • H54.0X33 Blindness, right, left category 3 • H54.0X34 Blindness, right, category 3, left category 4 • H54.0X35 Blindness, right, category 3, left category 5 JAM

  15. New ICD-10 Codes – 2018 • H54.- Blindness & low vision • H54.0 Blindness, both • H54.0X Blindness, both, different category levels • H54.0X4 Blindness, right, category 4 • H54.0X43 Blindness, right category 4, left category 3 • H54.0X44 Blindness, right category 4, left category 4 • H54.0X45 Blindness, right, category 4, left category 5 JAM

  16. New ICD-10 Codes – 2018 • H54.- Blindness & low vision • H54.0 Blindness, both • H54.0X Blindness, both, different category levels • H54.0X5 Blindness, right, category 5 • H54.0X53 Blindness, right category 5, left category 3 • H54.0X54 Blindness, right category 5, left category 4 • H54.0X55 Blindness, right, category 5, left category 5 JAM

  17. New ICD-10 Codes – 2018 • H54.- Blindness & low vision • H54.0 Blindness, both • H54.0X Blindness, both, different category levels • H54.0X5 Blindness, right, category 5 • H54.0X53 Blindness, right category 5, left category 3 • H54.0X54 Blindness, right category 5, left category 4 • H54.0X55 Blindness, right, category 5, left category 5 JAM

  18. New ICD-10 Codes – 2018 • H54.1 Blindness, one eye & low vision other eye • H54.10 Blindness, one eye, unspec • H54.11 Blindness, right, low vision left • H54.113 Blindness, right category 3, low vision left • H54.1131 Blindness, right category 3, low vis left cat 1 • H54.1132 Blindness, right category 3, low vis left cat 2 JAM

  19. New ICD-10 Codes – 2018 • H54.1 Blindness, one eye & low vision other eye • H54.10 Blindness, one eye, unspec • H54.11 Blindness, right, low vision left • H54.114 Blindness, right category 4, low vision left • H54.1141 Blindness, right category 4, low vis left cat 1 • H54.115 Blindness, right category 5, low vis left • H54.1151 Blindness, right category 5, low vis left cat 1 • H54.1152 Blindness, right category 5, low vis left cat 2 JAM

  20. New ICD-10 Codes – 2018 • H54.1 Blindness, one eye & low vision other eye • H54.10 Blindness, one eye, unspec • H54.11 Blindness, right, low vision left • H54.114 Blindness, right category 4, low vision left • H54.1141 Blindness, right category 4, low vis left cat 1 • H54.115 Blindness, right category 5, low vis left • H54.1151 Blindness, right category 5, low vis left cat 1 • H54.1152 Blindness, right category 5, low vis left cat 2 JAM

  21. New ICD-10 Codes – 2018 • H54.1 Blindness, one eye & low vision other eye • H54.10 Blindness, one eye, unspec • H54.12 Blindness, left, low vision right • H54.121 Low vision, right, cat 1, blindness left • H54.1213 Low vision, right, cat 1, blindness left, cat 3 • H54.1214 Low vision, right, cat 1, blindness left, cat 4 • H54.1215 Low vision, right, cat 1, blindness left, cat 5 JAM

  22. New ICD-10 Codes – 2018 • H54.1 Blindness, one eye & low vision other eye • H54.10 Blindness, one eye, unspec • H54.12 Blindness, left, low vision right • H54.122 Low vision, right, cat 2, blindness left • H54.1223 Low vision, right, cat 2, blindness left, cat 3 • H54.1224 Low vision, right, cat 2, blindness left, cat 4 • H54.1225 Low vision, right, cat 2, blindness left, cat 5 JAM

  23. New ICD-10 Codes – 2018 • H54.2 Low vision, both • H54.2X1 Low vision, right, cat 1 • H54.2X11 Low vision, right, cat 1, low vision, left, cat 1 • H54.2X12 Low vision, right, cat 1, low vision, left, cat 2 • H54.2X2 Low vision, right, cat 2 • H54.2X21 Low vision, right, cat 2, low vision, left, cat 1 • H54.2X22 Low vision, right, cat 2, low vision, left, cat 2 JAM

  24. New ICD-10 Codes – 2018 • H54.4 Blindness, one eye • H54.40 Blindness, unspec • H54.41 Blindness, right, normal left • H54.413 Blindness, right, cat 3 • H54.413A Blindness, right, cat 3, normal left • H54.414 Blindness right, cat 4 • H54.414A Blindness, right, cat 4, normal left • H54.415 Blindness, right, cat 5 • H54.415A Blindness, right, cat 5, normal left JAM

  25. New ICD-10 Codes – 2018 • H54.42 Blindness, left, normal right • H54.42A Blindness, left, cat 3-5 • H54.42A3 Blindness, left, cat 3, normal right • H54.42A4 Blindness, left, cat 4, normal right • H54.42A5 Blindness, left, cat 5, normal right JAM

  26. New ICD-10 Codes – 2018 • H54.5 Low vision, one eye • H54.50 Low vision, unspec • H54.51 Low vision, right, normal left • H54.511 Low vision, right, cat 1-2 • H54.511A Low vision, right, cat 1, normal left • H54.512A Low vision, right, cat 2, normal left • H54.52 Low vision, left, normal right • H54.52A Low vision, left, cat 1-2 • H54.52A1 Low vision, left, cat 1, normal right • H54.52A2 Low vision, left, cat 2, normal left JAM

  27. CMS Incentive Programs • Physician Quality Reporting System (PQRS) • Health Information Technology (HIT/EHR) • Value-Based Payment Modifiers (VM) • Aoa.org/vbm-fact-sheet • Merit-Based Incentive Payment System (MIPS) • Starting in 2019, MIPS will combine VBM, PQRS, & EHR/MU • Begin rating doctors based on a 100 point scale reflecting performance on quality, resource use, clinical practice improvement activities & MU of EHR JAM

  28. MIPS Payment Adjustments • Quality Payment Program final policy released October 14, 2016 • Your performance in 2017 affects your bonus or penalty in 2019 for Medicare Part B • MIPS payment adjustment • 2016-18 = 0 • 2019 = +/-4% • 2020 = +/-5% • 2021 = +/-7% • 2022 = +/-9% JAM

  29. MIPS Eligible Providers • Physicians – participate as individuals, groups or “virtual groups” • Virtual groups composed of solo practitioner or groups of 10 or fewer clinicians, who come together “virtually” with at least 1 other such solo practitioner (2 or more TINs) or group to participate for a performance year (requirements are the same) • Physician Assistants ((PA) • Nurse Practitioners (NP) / Clinical Nurse Specialists (CNS) • Certified Registered Nurse Anesthetists (CRNA) • Groups that include such clinicians JAM

  30. MIPS Virtual Group Identifiers • Created a “Virtual group participant identifier” • Identifier would be combination of three identifiers • Virtual group identifier • TIN (9 numeric characters) • NPI ( 10 numeric characters) JAM

  31. MIPS Eligible Providers • Next generation ACOs • Comprehensive Primary Care Plus • Medicare Shared Savings Program (MSSP) • Oncology Care Model with two sided risk • Comprehensive End Stage Renal Disease Care • for larger dialysis organizations JAM

  32. 10 Things to Know About MACRA 2018 • Pick-your-pace transition plan continues in 2018 • Use of 2015 certified HER is now optional in 2018 • CMS has increased the low volume threshold exclusion, and 63% of all Medicare clinicians will be exempt from MIPS in 2018 • Cost will remain 0% of the overall MIPS score in 2018 • Providers can participate in MIPS as individuals, groups or virtual groups JAM

  33. 10 Things to Know About MACRA 2018 6. CMS will allow multiple submission mechanisms within the ACI, quality & improvement activities categories 7. CMS will offer small practices “significant hardship” exceptions to opt out of MIPS ACI starting in 2018 8. CMS made only minor changes to the Advanced APM regulations, requires use of certified EHR 9. Adds bonus points to final MIPS score for Sm Practices 10. 2018 Rule includes several wins (small practices) as Trump Admin makes efforts to reduce regulation JAM

  34. MACRA / MIPSCosts of Final Rule • $857 million in collection of information related burden • $4.8 million in regulatory review costs • Federal expenditures will include $173 million in revenue neutral payment adjustments plus $500 million in “exceptional” performance payments • Additional federal expenditures include $590-800 million in APM incentive payments JAM

  35. MIPS Transition Flexibility • CMS continues to allow flexibility in 2018 reporting • Allows providers to avoid penalties for 2020 • MIPS Options for Transition Year • Do Nothing = 4% penalty in 2019 • Submit “some” data = avoid penalties in 2019 • Partially participate in MIPS = eligible for small bonuses • Fully participate in MIPS = eligible for larger bonuses • Pick-your-pace transition plan continues in 2018 • Payment adjustment will depend on how much data you submit & your quality results JAM

  36. MIPS Transition Flexibility • -% = DON’T PARTICIPATE and receive a -4% reduction • 0% = TEST by submitting a minimum amt of 2017 data (ex. 1 quality measure or 1 practice improvement activity) thereby avoiding downward payment adjustment • +% = PARTIAL participation more than 1 quality measure or more than 1 practice improvement activity at any time in 2017 and qualify for a small bonus • ++% = FULLY participate by submitting 90 days or up to 1 year of 2017 data for moderate bonus in 2019 JAM

  37. MIPS Transition Flexibility • MIPS is budget neutral • If few providers receive penalties the bonuses would be lower to maintain neutrality with maximum of 4% • Exceptional performance • Providers who fully participate • Earn a MIPS score of 70 or higher • Qualifies for additional bonus of 0.5% or higher • Capped at 10% • Funded by $500 million authorized by law JAM

  38. Can You Be Excluded from MIPS ? • If you see 200 or fewer Medicare part B patients per year or • If you have $90,000. or less in Part B allowed charges per year • If you are newly enrolled in Medicare during the reporting year • If you participate in an Advanced APM that meets the required thresholds • Continued exemptions dwindle the number of MIPS eligible clinicians to 36%, but they make up 58% of Medicare Part B charges JAM

  39. MIPS Categories for Scoring • Quality Measures (PQRS/QP) = 50% (60% in 2017) • Advancing Care Information (ACI/MU) = 25% • Clinical Practice Improvement Activities = 15% • Resource Use (Cost) = 10% • MIPS Final Score of 100 • Final score of 15 will avoid negative payment adjustment • Achieved by submitting 1 quality measure or 1 practice improvement activity (CPIA) • Final score of >15 and <70 eligible for small bonus to 4% • Final score of >70 eligible for bonus of at least 0.5% (capped at 10%) from funds for “exceptional performance” JAM

  40. EHR and MU Changes in MIPS in 2017 • EHR / MU renamed “Advancing Care Information” • 2017 is a transition year for ACI • Requires reporting 4 measures to earn any ACI credit • Report these 4 measures on a single patient and you earn ACI credit for the “Base Score” • Practices can report individually or as a group • Patient portal measures are optional • View, download, transmit and secure messaging • Scribe certification requirement eliminated JAM

  41. EHR and MU Changes in MIPS in 2018 • In 2018 providers not required to upgrade to the 2015 edition of certified EHR technology as directed in 2017 • Allows use of 2014 or 2015 Edition CEHRT in 2018 • Grants a bonus only for using 2015 Edition CEHRT • Hardship exemptions continue in MIPS • Category re-weighted to zero, points shifted to Quality score • New hardship exception for small practices (15 or fewer clinicians) • Change the deadline for exception application submission for 2017 and future years to December 31 of performance year • Adds a decertification exception for clinicians whose EHR was decertified JAM

  42. Advancing Care Information Scoring • ACI Score is 25% of MIPS Score • Total possible Score 155% • Base score (50%) – required to earn any credit under ACI • Performance score (up to 90%) • Bonus score (up to 15%) • Highest Acheivable score is 100% • Scores over 100 will total 100 & earn full 25 points for ACI • Base score is “All or None” – report each required ACI measure once and get 12.5 points • Performance score – credit awarded based on achievement level for each measure JAM

  43. ACI Requirements for Base Score • Security Risk Analysis – conduct or review a SRA, implement updates, correct identified deficiencies • Electronic prescribing – at least 1 permissible prescription written is queried for a drug a drug formulary and transmitted electronically using a CEHRT • Patient Electronic Access: Provide Patient Access – at least 1 unique patient is provided timely access to view online, download and transmit his/her PHI • Health Information Exchange – at least 1 patient is transitioned or referred to another setting or clinician including creating summary of care and e-exchanged JAM

  44. ACI Requirmt for Performance Score • Report these measures to earn performance score based on achievement • Patient Electronic Access • Provide access – up to 20% • View download, transmit – up to 10% • Patient Specific Education – up to 10% • Secure Messaging – up to 10% • Health Information Exchange – up to 20% • Medication Reconciliation – up to 10% • Immunization Registry Reporting – 0% or 10% • Allows no reporting, 5-10% for reporting to additional registries JAM

  45. ACI Requirement for Bonus Score • Participate in a specialized Registry – 5% bonus score • Complete a Clinical Practice Improvement Activity (CPIA) using a CEHRT – 10% Bonus Score • Ex. Provide 24/7 access to provider for urgent or emergent care or advice • Using CEHRT Secure Messaging functionality to provide this care • Ex. Sending and responding to secure messages outside of normal business hours JAM

  46. Quality Program in MIPS • Report 1 Quality measure at any point during the year • Can report using Registry, EHR, or Claims • As little as 1 measure on one patient avoids penalty! • Eligible to earn Small Bonus – successfully report more than 1 measure at any time during the year • To Maximize Quality Score – for minimum of 90 days, report 6 measures using Registry, EHR or claims • Report on at least 60% of applicable patients • Medicare only for claims reporting • All payers for Registry & EHR reporting • 1 measure must be an “Outcome” or “High Priority Measure” JAM

  47. Quality Program Scoring in MIPS • Quality Scoring is 50% of MIPS • Each of the 6 measures is worth from 3-10 points depending upon your success on each measure • Each measure reported will earn a minimum of 3 points • Even if not reported for 90 days • Even if not reported on 50% of eligible patients • Outcomes Measures – 2 bonus points per measure awarded for additional outcomes measures when more than one outcomes measure reported • EHR or Registry-EHR integration – 1 bonus point awarded for electronically reporting quality measures JAM

  48. Quality Program Measures Update • New & revised ICD-10 codes now required • No longer required to report from specific quality domains • Required to report from at least one measure that is • Outcome or High priority • Data submission requirement by method • Claims reporting – processed within 60 days of end of performance period (March 1, 2018) • Manual registry reporting – submitted by March 31, 2018 • EHR reporting – submitted by March 31,2018 • https://qpp.cms.gov/. JAM

  49. Quality Measures: eCQMs MIPS • DM: HA1c Poor Control (>9%) – Outcomes • Closing referral loop: receipt of specialist report – High P • Documentation of current medications in Record – High P • Preventive care/screening: BMI screening & F/U • Pneumonia vaccination status older adults • DM: eye exam • Cataracts complication w/in 30D of Sx – Outcomes • Cataracts: 20/40 or better VA w/in 90 D – Outcomes • Preventive care/screening for Tobacco Use • Falls: Screening for Fall Risk – High Priority JAM

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