Chiropractic and the MACRA Legislation

What Is All the Fuss about the MACRA Legislation, and Why Should I Care?

MACRA and Your Chiropractic Documentation

You might have heard about the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) legislation when it initially came out in April 2015. Many chiropractors heard about it then because it detailed how chiropractic documentation has been less than ideal for many years, what steps were needed to improve chiropractic documentation and the negative consequences that will befall the worst chiropractic offenders. Based on findings from impromptu surveys from chiropractors held at chiropractic seminars around the country, this critical information about MACRA and chiropractic documentation is still little known to the typical chiropractor.

A serious concern is that the average chiropractor does not know that chiropractic documentation (and therefore chiropractic) is under such harsh scrutiny by the Federal government. Many DCs are unaware that 2016 is the year our profession needs to get our documentation ducks in a row.

There has been an increase in the number of chiropractic Medicare audits this year. Have you noticed an increase in records request in your chiropractic practice? Get help to evaluate where you, and your chiropractic records, stand before you respond to that Medicare records request! KMC University compliance specialists can assist you with getting it right the first time, when it comes to responding to a Medicare audit request. You will not get a second chance to make a good first impression. If you do not respond correctly to a Medicare audit request, you can be setting yourself up for a lot more Medicare requests.

It is anticipated that chiropractic Medicare audits will continue to increase in number as the year progresses, in preparation for determining error rates for individual chiropractors. Because of a provision in the MACRA legislation, as of January 2017, chiropractors will be held to the standard Medicare expects to see in our chiropractic documentation. Chiropractors with a documentation/billing/coding error rate of 85% or more will be subject to Medicare pre-payment auditing.

MACRA and the Quality Payment Program

The MACRA legislation replaced the sustainable growth rate (SGR) formula that had been used by Medicare since 1997 to determine the Medicare Physician Fee Schedule (MPFS) each year. The first step in this journey of replacing the SGR, was to set an annual 0.5% update to the Medicare Physician Fee Schedule now through 2018.

Beginning with the reporting period of 2017, the Centers for Medicare and Medicaid Services (CMS) has been tasked with converting payment increases to providers via the Quality Payment Program.  It’s important to remember that your reporting on quality programs are applied as a result two years later, for example, 2015 reporting will impact 2017 fees.  This Quality Payment Program is designed to incentivize healthcare providers, including chiropractors, to value quality care (clinical outcomes) over the quantity of care rendered (number of services provided) and is planned for 2019 fees.

This new Quality Payment Program will include one of two payment options for healthcare providers (including chiropractors): the Merit-based Incentive Payment Systems (MIPS), or an Alternative Payment Model (APM) payment system. As this new system is getting off the ground, all healthcare providers, including chiropractors will report through the MIPS in the first year to determine which clinicians might qualify for the APM possibility in subsequent years.

CMS being tasked with tying quality of care with payments for that healthcare is not new. The CMS Quality Payment Program is a continuation, streamlining and refinement of other quality-based programs that have been in existence for a number of years. CMS is, and has been, incentivizing quality of care with these predecessor (current) programs: the Physician Quality Reporting System (PQRS), the Medicare Electronic Health Records (EHR) Incentive Program and the Value-based Payment Modifier (VM) programs. Now these established programs, PQRS, EHR, and VM will be ‘merged’ and incorporated in the new Merit-based Incentive Payment Systems (MIPS) program, as a way to streamline and simplify the reporting process.

Currently, CMS has a goal for 30% of Medicare payments to be tied to quality or value through alternative payment models by the end of 2016, and 50% of payments tied to quality/value by the end of 2018. Additionally, Medicare has a goal for 85% of the fee-for-service payments tied to quality/value by the end of 2016 and 90% by the end of 2018.

MACRA and MIPS

MIPS is a new program that streamlines the three current programs and adds a fourth component to promote ongoing improvement and innovation to clinical activities. These four performance categories will combine to form a MIPS Composite Performance Score (CPS). Let’s look at each component:

• Quality – This category replaces the PQRS system, includes measures to include one cross-cutting measure and one outcome measure or another high priority measure if an outcome measure is unavailable. 2017 weight of 50% of total CPS score.
• Resource Use (Cost) – This category replaces the cost section of the Value-based Payment Modifier Program. It will be based on your Medicare claims, therefore there are no reporting requirements for this component. 2017 weight of 10% of total CPS score.
• Clinical Practice Improvement Activities – This is a new category beginning in 2017. A minimum of one of the proposed 90+ Clinical Practice Improvement Activities (CPIA) reported, with additional credit for more activities is proposed. These CPIAs would include things like coordination of care, patient safety and shared decision-making. 2017 weight of 15% of total CPS score.
• Advancing Care Information – This measure is an update of your current EHR attestation. It is anticipated that this score will decrease as EHR adoption becomes more universal. 2017 weight of 25% of the total CPS score.

MIPS Participation

Participation in MIPS include physicians, PAs, NPs, clinical nurse specialists, certified registered nurse anesthetists, and Medicare has made the following note regarding chiropractors and their participation in MIPS: Physician includes: a doctor of chiropractic legally authorized to practice by a state in which he/she performs this function.

Those not eligible to participate in MIPS include: first year of Medicare part B participation, low patient volume (Medicare billing charges less than or equal to $30,000 and provides care for 100 or fewer Medicare patients in one year) and certain participants in Advanced Alternative Payment Models.

Performance periods for MIPS reporting are one full calendar year. The MIPS reporting requirements should be finalized by the end of 2016 and are planned to be in effect in 2017.  That performance period will impact the 2019 payment year.  Each reporting year impacts the payment year two years in the future, for example, 2018 is the performance period with 2020 being the payment year for that (2018) performance period.

MACRA Conclusion

The above information is based on the proposed rule and is subject to change until the final rule is published later in 2016. As healthcare providers, we chiropractors must be aware and watch for dramatic changes in third-party payer behaviors as a result of this legislation, so we can be prepared to successfully transition to this new system. Important action steps for you and your chiropractic practice to meet this challenge are:

• Review your chiropractic documentation to ensure you are currently compliant with the Medicare documentation requirements for chiropractors.
• Master your written case management, to improve your clinical outcomes.
• Reconsider a shift from paper documentation to EHR documentation in your chiropractic practice.
• Ensure you have a current Compliance Program installed, including self-auditing, to assist you in self-policing your own chiropractic documentation, chiropractic case management, etc. in an effort to minimize errors that will happen through human error.
• Stay in tune with Medicare updates from a reliable source so you can implement any reporting standards as they are approved and finalized.

The typical chiropractor went to chiropractic college to learn how to treat and adjust patients. Keeping up with changing healthcare regulation, like the MACRA legislation, can seem like it is 180 degrees from where your attention should be in practice today. That is where we can bridge the gap. Our KMC University compliance specialists are experts in Medicare documentation requirements for chiropractors and can assist you in your chiropractic documentation self-evaluation process. We have a turnkey compliance program ready for you to install in your chiropractic practice, to minimize your compliance risks. This compliance program is designed so a team member can complete the installation and monitor this process for your chiropractic practice.

Be aware of the changing healthcare environment and use tools and systems to successfully navigate the changes ahead. Then you can get back to your core focus of taking care of patients!

Dr. Dianne M Baynes, RN, DC, MCS-P, CPPM, brings a lifetime of experience in healthcare to KMC University, from teenage candy-striper to registered nurse to top-of-her-class and innovative chiropractor. She implements solutions and teaches DCs and CAs how to thrive in the world of healthcare compliance and still have a passion for chiropractic. She can be reached at info@KMCUniversity.com, or by calling 855-832-6562. www.KMCUniversity.com