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Preparing for 2011 – Where are we and where are we going. Cathie Biga President/CEO Cardiovascular Management of Illinois. Agenda. 2010 in review Technical Correction 2011 Physician Fee Schedule 2011 HOPPS Private Payers in 2011 HCR/ACA – its impact Core 2011 concepts: PQRS/eRx….

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preparing for 2011 where are we and where are we going

Preparing for 2011 –Where are we and where are we going

Cathie Biga


Cardiovascular Management of Illinois

  • 2010 in review
  • Technical Correction
  • 2011 Physician Fee Schedule
  • 2011 HOPPS
  • Private Payers in 2011
  • HCR/ACA – its impact
  • Core 2011 concepts: PQRS/eRx….

Primary Issues

  • Threats to physician ownership/in-office imaging
  • SGR – will it ever be fixed
  • IPAB
  • CMI

Secondary Issues

  • Key topics – 1) Disclosure requirements for CT, PET, MRI, 2) PECOS, 3) POS/DOS, 4) Timely filing
  • 2012 Accreditation of labs and 2010 IAC changes
  • Meaningful use – stretch or a barrier?
  • PFS 2011
    • 2nd year of PPIS implementation
    • Bundling continues
    • Rebase for MEI
    • RUC focus
  • HOPPS 2011
    • Reductions beginning?
  • Quality focus continues to grow
  • Ongoing scrutiny of imaging and IOE
  • EP becomes its own specialty 4/4/11
  • Gap in technical
    • Bundling of nucs ’10
    • Bundling of caths ’11
    • Massive PV bundling
  • RAC’s, MACs, and other attacks
  • Revenue wherever you can find it
    • Clinical integration
    • PQRI
    • eRx
    • Meaningful use
  • Operational efficiencies
  • New product lines
technical correction
Technical Correction

What is it

What do we do

What have people done

Current status

what is the real story
What is the real story

In May of 2010 the updated files also contained updates to RVU units. This has a range of .60 refunds to $50 –$60 increases for some services

technical correction1
Technical Correction
  • $2M just appropriated for re-filing
  • How to handle both the upside….and the downside
  • Patient responsibility
  • Secondary's
  • You have to love it…
2011 fee schedule
2011 Fee Schedule
  • Be sure you have downloaded the one with the $33.97 CF
  • Let’s walk through the key elements and lo lights
medicare formula

{(RVU work x GPCI work) +

(RVU practice expense x GPCI practice expense) + (RVU malpractice x GPCI malpractice)}

conversion factor x BN


Medicare formula

Resource Based Relative Value Scale

Payment =

RVU = Relative Value Unit

GPCI = Geographic Practice Cost Indices


SGR ….

Rollercoaster throughout 2011

13 month “fix”

That only cost $19 BILLION

No increase for physicians

After the May technical correction the CF was $36.8729

Sunset – Dec 1, 2010 (was to be a 23.6% hit)

Sunset – Jan. 1, 2011 – 12 month extension

2011: Conversion Factor = $33.9764

mei impact
MEI …impact

CMS is rebasing and revising the MEI to use a 2006 base year in place of a 2000 base year.

This update to the MEI is the first time it has been rebased and revised since 2004.

For practices with high technical this will result in an increase

Total RVU’s attributed to work will see a decrease

Bottom line – mitigated a bit of the PPIS hit

Resulted in a major CF change

why do my fees keep changing rvu changes
Why do my fees keep changing RVU changes

This is the last year of a 4 yr phase in on how PE are determined – we are DONE with this

This is the 2nd yr (of a 4 yr plan) due to the PPIS

This is the 1st time MEI has been re-based

The RUC keeps messing with us



other key factors of 2011 fee schedule
Other key factors of2011 Fee schedule

Financial Disclosure letter and sites


Time of referral

5 suppliers within 25 miles

Document compliance

EU rate – 75%

Multiple procedure reduction

Affects technical component

25% increases to 50%


Echo payment reduced – 13.5%

PET reduced

Supervision re-defined

Hospital outpt on campus

Hospital outpt off campus

private payor shenanigans
Private payor shenanigans


Substitute echo for nuc

United pre-notification

Humana pre-notification

Report cards

hcr aka aca
  • Grandfathered and non-grandfathered plans
  • Coverage
  • Lifetime limits
  • Equipment Utilization: The ACA overrules the fee schedule and will lock this rate at 75%
  • House energy and commerce – J.Pitts
      • my first legislative priority will be wholesale repeal of the health law, which will pass the House, I'm sure, but realistically won't get past the Senate or the president.
  • ACA law requires that PCMHs be exclusively primary physician based, how do we ensure specialty based PCMH models can be authorized
  • Drivers
    • HCR
    • MedPac and imaging scrutiny
    • Payment reform mandates
    • HOPPS vs PFS
  • Is it here to stay?????
aco s

Rules due out in Jan

ACA attributes patients to ACOs (by virtue of the doctors and hospitals they currently use) ---patients do not enroll in them.

This is confusing, because if patients do not want to be in an ACO and instead stay with their doctor who chooses not to participate, they may. But if their doctor is in, so is the patient. This issue may need to be amended somehow

auc where is it going
AUC…..where is it going

Midei case in Baltimore

ACE from SCAI (accreditation for cardiovascular excellence)

JAMA article on ICD

FOCUS – nuclear

Lab accreditation


IAC – focus on use of AUC

quality where is it going
Quality …where is it going?

Recent CMS report

3 demo projects

Hospital Quality Incentive Demonstration (HQID)

the Physician Group Practice (PGP)

500 small and solo physicianpractices participating in the Medicare Care Management Performance (MCMP

physician compare
Physician Compare

Public reporting of data

Starts 1/1/13

Mandated by ACA

Physicians need to be able to update their contact info

Comment period is now

few more
Few more….

Sunshine Act


Anything over $10 will be reported


CMS is working “diligently”

Edit not turned on for referring MD

NO DATE has been announced

Red Flag – finally gone

what is this new moc
What is this “new” MOC

MOC = Maintenance of certification

Additional .5% in PQRS payments if enrolled in MOC

Must submit PQRS data for 12 months, participate in MOC, and complete MOC practice assessment


pqrs aka pqri

PVRP was initial program in 2006

PQRI - 7/1/07 – 1.5% incentive payment

2008 – Few structural changes

2009 and 2010 - 2% incentive payment

Yes you can do this + Meaningful use

2011 – Physician Quality Reporting System

194 measures

pqrs resources
PQRS Resources

A Guide for Understanding the 2011 Physician Quality Reporting System (PQRS) Incentive Payment

key changes
Key Changes

Penalties start in 2015

2011 – 1% payment

2012 – 2014 - 0.5% payment

Reporting sample reduced from 80% to 50% for claims ONLY

Registry still must meet 80% on 3 measures

Registries no longer can report on non-Medicare FFS

Measures with 0% will not be counted

New group reporting option <200

26 measures

changes to structure and function
Changes to Structure and Function

In response to ACA

Penalty: 1.5% in 2015 & 2.0% after

Timely feedback

Interim reports

Informal appeal process

Physician Compare Website

Reports 2012 PQRS

Integration with MU


170 measures continue (24 new)

45 registry measures continue

11 new registry only

14 Measure Groups

EHR current 10 + 10 new

pqri 2011
No Changes

#6 – CAD on Antiplatelet

#7 – CAD prior MI on BB

#47 – Advance Care Plan

#124 – Use of EMR

#201 - IVD & BP Control

#202 - IVD & Lipid Profile

#203 – IVD & LDL


#128 – BMI Screening & Follow Up

#226 –Tobacco Screening & Cessation

#235 – HTN Plan of Care


#5 – HF on ACE/ARB

#8 – HF on BB

(remove Cardiomyopathy codes)

#114 – Smoking Screening

#115 – Smoking Cessation


#118 – CAD on ACE/ARB & DM and/or LVSD

(remove Pregnancy Diabetes codes)

PQRI 2011
erx for 2011
eRx for 2011

Can NOT do in addition to MU

You can do eRx + PQRI

1% Incentive payment

Need to do 25 instances

2011 report for entire year

Penalties start in 2012



See pgs 1305 to 1307

MUST have an approved system

10 instances per provider from Jan1 – June 30, 2011

Must do even with MU

Must do via CLAIMS

Submit the G code to prevent penalty

Not only does 2011eRx determine 2012...but  it also locks you in for the penalty!

the penalty
THE Penalty

You can NOT use EHR or registries to submit

Yes you can receive incentive money……..and still be penalized

Penalties will be NPI specific

CMS needs info by 12/21/11

Are they reaching beyond their legal scope?

are there any exceptions
Are there any exceptions…

Provider does not have at least 100 cases containing an encounter code in the measure denominator

Provider does not meet the 10% denominator threshold

For the 2012 eRx payment adjustment, the following circumstances would constitute a hardship:

The eligible professional practices in rural area with limited high-speed internet access, or

The eligible professional practices in an area with limited available pharmacies for electronic prescribing

G-codes have been created to address two hardship circumstances (G8642 and G8643)

To request a hardship exemption for 2012 payment adjustment: An eligible professional must report the appropriate G-code on at least 1 claim prior to June 30, 2011

erx comparison
eRx Incentive 2011

Attached to an E&M code

Use Code G8553

Must submit 25 eRx Medicare patients to get 1% incentive

Reported on claims or Registry

eRx Penalty 2012 & 2013

Attached to an E&M code

Use Code G8553

Must submit 10 eRx Medicare patients between January and June 30, 2011 to avoid 1% adjustment in 2012

Report on Claims only

Must submit 25 eRx Medicare patients between January and December 31, 2011 to avoid 1.5% adjustment in 2013

Report on Claims or Registry

eRx Meaningful Use

Does not tie to an E&M code

Doesn’t use G codes

Must have more than 40% of all permissible prescriptions transmitted electronically

Tracks faxed, printed or e-prescribed prescriptions

Excludes Controlled Substances

Applies to all patients, not specific to Medicare

eRx Comparison
qualified erx system is
Qualified eRx system is…

Must do ALL of the following

Generate an Active medication list

Incorporates e data from pharmacies and pharmacy benefit managers

Select meds, print prescriptions, transfer electronically, and conduct ALL alerts:

Provide info on lower cost alternatives

Tiered formulary info is sufficient in 2010

Provide info on formulary or tiered formulary medications, pt. eligibility, and authorization requirements received electronically from pt’s drug plan

lessons learned
Lessons learned

Remember the 10% rule

Don’t forget mid levels

How penalty will be applied…

is it worth it
Is it worth it???
  • Clinical Integration $134,940
  • Clinical Integration $272,114
  • PQRI @ 2% $219,175
  • PQRI @ 2% $167,915
  • eRx @ 2% $174,473
  • eRx @ 2% $168,652


Personally I think that is REAL money

meaningful use
Meaningful Use

25 Objectives and Measures

15 Core Mandatory Measures

10 Menu Measures (Must meet 5 out of 10)

6 Total Clinical Quality Measures

3 Core

3 out of 38 from Menu set


8 Measures reported through Attestation

1 Measure reported with Numerator and Denominator and Exclusion through Attestation (Clinical Quality Measures)

16 Measures reported through Numerator and Denominator

Reporting Period

First year of demonstration: Any continuous 90-day period within the payment yearin which you successfully demonstrate Meaningful Use

Second payment year and beyond: The EHR reporting period will mean the entire payment year

meaningful use core measures
Meaningful Use = Core Measures
  • CPOE = 30%
  • Drug-Drug and Drug-Allergy Interaction Checks
  • Up-to-Date Active Diagnoses List = 80%
  • eRx = 40%
  • Active Medication List = 80%
  • Active Allergy List = 80%
  • Demographics (Race, Ethnicity, Preferred Language, DOB, Gender) = 50%
  • Vital Signs (Height, Weight, BP) = 50%
  • Smoking Status = 50%
  • Clinical Quality Measures
  • One Clinical Decision Support Rule
  • Electronic Copy of Health Information upon Request within 3 business days (Patients only) = 50%
  • Clinical Summaries each OV = 50%
  • One Test to Electronically Exchange Clinical Information
  • Security Risk Analysis
meaningful use menu measures
Meaningful Use = Menu Measures
  • Drug Formulary Checks ***
  • Lab Results = 40%
  • Patient Report with Specific Condition ***
  • Reminders for Preventive/Follow Up Care = 20%***
  • Electronic Access to Health Information within 4 business days = 10%
  • Patient Education = 10% ***
  • Medication Reconciliation = 50%
  • Summary Care Record with Transition of Care = 50%
  • Immunization Registry ***
  • Public Health Surveillance
getting ready
Getting Ready
  • Smoking Changes
    • Risk Factor
    • Cessation Pick list
measure 7 demographics
Measure 7 - Demographics
  • Need all fields filled in
    • DOB
    • Gender
    • Preferred Language
    • Race
    • Ethnicity
  • Goal = 50% or better

A = 44%

C = 38%

H = 29%

thank you