Retina specialists, like all other health care providers, are still adjusting to the new and evolving value-based landscape. Most retina practitioners are operating under the Merit-based Incentive Payment System (MIPS), one of two tracks under Medicare’s Quality Payment Program. The 2017 MIPS performance year was a transition period — a time for providers to learn how to navigate MIPS by developing strategies to succeed in this new environment. With potential positive and negative payment adjustments at stake, improving care and reducing costs are critical if providers want to achieve high MIPS scores in 2018 and beyond. To accomplish this goal, retina specialists must transform their operations and care delivery to adhere to the new rules governing value-based reimbursement.

COMORBIDITIES AND HIERARCHICAL CONDITION CATEGORY CODING

How retina specialists deliver and document care for patients with comorbidities, such as diabetes and high blood pressure, will play an important role in how well they perform in the new value-based environment. Properly monitoring, documenting, and reporting care delivery can have a positive impact on MIPS scores, resulting in higher quality measure scores and receiving credit for the acuity of the growing high-risk patient group through the complex patient bonus.

Expensive drugs, such as Lucentis (ranibizumab; Genentech) and Eylea (aflibercept, Regeneron), can have a significant negative impact on the MIPS composite score, especially under the cost category, if documentation does not support the need for the drugs. Accurate documentation and coding substantiate the cost of care, a critical component of value-based care that is closely scrutinized by private payers and the Centers for Medicare and Medicaid Services (CMS). In 2018, the cost category accounts for 10% of a provider’s MIPS score, and next year it will jump to 30%. Consequently, it is critical for retina specialists to understand how cost affects them and to develop strategies to avoid a negative impact in this category.

To properly account for the high cost of care in treating patients with a chronic condition or multiple comorbidities, providers should utilize the CMS Hierarchical Condition Category (HCC) coding. HCCs are specific disease groups arranged by body systems or similar disease processes. HCC codes were developed by CMS to give weight or value to chronic conditions that are known to worsen over time. Reimbursement based on HCC coding more accurately reflects the patient’s actual condition and the true expected cost of care, rather than relying on an average payment amount determined by CMS. Hierarchical Condition Category coding is the only way under MIPS to account for sicker patient populations so the composite score is not negatively impacted. It enables providers to substantiate the need for high-cost drugs and other services that are commonly required to provide quality care to patients with chronic conditions.

In addition to understanding HCC coding and how it can impact their MIPS score, retina specialists also need to be aware of how these codes affect their Risk Adjustment Factor (RAF), an actuarial tool used to predict health care costs by identifying whether a patient has a chronic condition that puts him or her at a higher risk for more expensive care. Under MIPS, the RAF plays a critical role in determining the payment adjustment providers will receive for the care they deliver.

The MIPS cost category score is based on 2 measures that CMS pulls from eligible clinicians’ claims:

• Medicare Spending per Beneficiary (MSPB), which examines the cost of all Part A and B charges for an inpatient episode, and
• Total per Capita Cost (TPCC) for all beneficiaries attributed to the MIPS eligible clinician.

The TPCC is risk adjusted based on HCC diagnosis coding that identifies beneficiaries with chronic conditions and other factors, such as Medicaid status, that historically contribute to higher costs of care year over year. HCC coding increases a beneficiary’s RAF and protects clinicians against penalties in the cost category. Patients with a RAF of greater than 1.0 are considered by Medicare to have chronic conditions that will require more funding than the standard Medicare approved amount. HCC coding is the only way providers can demonstrate to CMS why their patients are sicker than others and why there is a higher than average cost of care. Consequently, it is imperative that retina specialists understand HCC codes and know how to document the appropriate code to receive proper credit for the high-risk patients attributed to them.

Some retina practices are already familiar with HCC codes, as these codes are part of the new ICD-10 diagnosis coding system that went into effect in October 2015. However, many practices may still not be aware they should be using HCC codes whenever possible to document the true condition of the patient. Hierarchical Condition Category codes will most likely be discussed at greater length across the industry this year, especially because the MIPS cost category is coming to the forefront.

BUILDING A FOUNDATION TO MAXIMIZE MIPS SCORES

Comorbidities have a huge and growing impact on the MIPS scorecard, and they must be documented appropriately if providers want to maximize reimbursement and avoid penalties. If retina specialists are not already documenting and reporting these chronic conditions or prepared to do so, now is the time to get up to speed by tackling the following tasks:

• Examine data in the electronic health record (EHR) to identify the high-risk patient population. Providers who belong to the IRIS registry can access many resources from the organization to assist with this undertaking.
• Thoroughly analyze the documentation of these patients with chronic conditions to determine where HCC codes can be incorporated. Coding experts or consultants can assist with this, as well as retina organizations.
• Look at new patients coming into the practice to see if they are arriving with HCC codes already documented by the referring physician.
• Most importantly, develop a strategy going forward to incorporate HCC codes into the documentation process and the practice EHR.

Retina specialists can also improve their MIPS quality scores by enhancing the patient experience. Practices can implement improvement activities that will help engage patients and provide a better understanding of patient needs by utilizing surveys, questionnaires, patient portals, and other engagement strategies.

ADD QUALITY MEASURES THAT EMPHASIZE COMORBIDITIES

Selecting appropriate quality measures for MIPS reporting can help ensure MIPS payment adjustments are not negatively impacted by comorbidities. Retina specialists should not just focus on the measures they have previously reported on with the Physician Quality Reporting System (PQRS), but rather incorporate some new measures that address chronic conditions and that also have benchmarks to achieve. The American Academy of Ophthalmology, as well as IRIS, supports many MIPS quality measures for high-risk patients, such as those with diabetes and hypertension. Adding measures that emphasize comorbidities can potentially provide retina specialists with a bonus for improvement over the prior year. Practices should pay close attention to the benchmarks for these new measures to make sure they meet or exceed the established standard for high performance.

PRACTICES MUST EVOLVE WITH THE CHANGING LANDSCAPE

Value-based care is here to stay, and MIPS is only the beginning of many more alternative payment models yet to come. Retina specialists must adapt their way of doing business, transforming their practice in several key areas to meet the requirements of the value-based world.

Providers need to put their data to work — not just let it pile up on someone’s desk. By harnessing and utilizing the valuable information contained in the practice EHR, actionable insight can be gained to develop and implement a population health strategy that can improve outcomes, especially for patients with chronic conditions. Quality measures and improvement activities should be devised that incorporate and engage patients with chronic disease, driving better outcomes, a better patient experience and more cost-effective care for this high-risk group. Providers must also closely monitor their drug costs and utilize HCC codes to document and substantiate the need for high cost drugs whenever they are used. Retina specialists who pay close attention to these critical areas of their practice will be well on their way to succeeding in the new value-based environment. RP