CMS Value Based Payment Modifier Program

The recently passed Medicare Access and CHIP Reauthorization Act (MACRA) mandates that three major Medicare programs for physicians-the Physician Quality Reporting System (PQRS), the Electronic Health Record (EHR) Meaningful Use Program and the Value Based Modifier (VBM) Program be combined.  Currently, these programs  reward or penalize physicians based on measures of quality and the ability to demonstrate certain capacities within a practice.  Starting in 2019, these three CMS programs will be consolidated into a single program called the Merit-Based Incentive Payment System (MIPS).   Many optometrists understand the demands of the long-established PQRS and meaningful use of electronic health records programs.  However, the third performance measurement component, the Value-based modifier (VBM), is less understood by most optometrists.  The VBM is not a coding modifier that needs to be added to claims. The VBM is a compilation of quality and efficiency data that will affect optometry and other physicians' reimbursement in Medicare.  2015 is the first year that the VBM will impact the majority of doctors of optometry.  The impact on payment in 2017 will be based on optometrists' performance in 2015.  The VBM is intended to compile the costs of an individual physician's care compared with the outcome or results of that care.  The VBM puts optometrists and other physicians at risk for being paid less than normal Medicare fee-for-service rates.    Based on CMS analysis, a physician's score will be categorized as one of the following:  

Quality:  Low quality, average quality or high quality. 

Cost:  Low cost, average cost, high cost.

Based on these categorizations, physicians will may receive a payment increase, no payment change, or a payment penalty. 

Optometrists should be aware that the VBM will not only impact reimbursement in 2017, but participation with the VBM program will also help optometrists in the future as the new Merit Based Incentive Program in implemented.  Under MIPS, optometrists will continue to be annually evaluated based on the quality and costs of the care provided to patients.   

What ODs Need to Do in 2015 to Avoid VBM Payment Penalties in 2017    

1.  Participate in PQRS   

To determine whether an automatic VBM payment reduction will be applied to you, CMS will first review whether you participated in PQRS. To avoid an automatic VBM payment penalty, you must participate in the Physician Quality Reporting System (PQRS). (  

If you do not participate in PQRS, you will receive BOTH a PQRS payment penalty and a VBM payment penalty.  The PQRS penalty is 2% while the VBM penalty amount is based on practice size: 

Groups with between 2 to 9 EPs and physician solo practitioners will receive an automatic negative 2 percent payment PQRS penalty AND a 2 percent VM payment penalty.  (4% total) Groups with 10 or more EPs will receive an automatic negative 2 percent PQRS payment penalty AND a 4 percent VM payment penalty.   (6% total)   

Information on how optometrists can participate in PQRS is available at:   

2.  Access Your Quality Resource and Use Report (QRUR)   

On September 30, 2014, CMS made 2013 Quality and Resource Use Reports (QRURs) available to all physicians nationwide. The 2013 QRURs include data that assess your performance on cost measures and performance on quality measures including performance on three outcome measures.  The QRUR information will give you additional information regarding how CMS has assessed the cost and quality of care provided to certain patients and will help you to understand how the VBM will potentially impact reimbursement in 2017.    

Your QRUR will assign certain patients to you for the purpose of assessing the cost and quality of care provided to those patients. Patients are assigned to different physicians based on who provided the plurality (as measured by allowed charges) of the patient's "primary care services." When attributing patients to doctors, CMS starts by examining which primary care practitioners (defined as family medicine; internal medicine, general practice, geriatric medicine, nurse practitioners, physician assistants and clinical nurse specialists) provided the most primary care services to a particular patient.  CMS defines primary care services as the following CPT codes:  

99201-99205 New patient, office or other outpatient visit

99211-99215 Established patient, office or other outpatient visit

99304-99306 New patient, nursing facility care

99307-99310 Established patient, nursing facility care

99315-99316 Established patient, discharge day management service

99318 Established patient, other nursing facility service

99324-99328 New patient, domiciliary or rest home visit

99334-99337 Established patient, domiciliary or rest home visit

99339-99340 Established patient, physician supervision of patient (patient not present) in home, domiciliary or rest home

99341-99345 New patient, home visit

99347-99350 Established patient, home visit G0402 Initial Medicare visit

G0438 Annual wellness visit, initial

G0439 Annual wellness visit, subsequent   Once CMS has identified the patients attributed to you, CMS will analyze the cost and quality of care provided to those patients.   

ODs should note that any patients that are not assigned to a doctor or practice through this analysis based on primary care practitioners (as defined by CMS) are then evaluted to determine which non-primary care providers (including ODs) provided the plurality of primary care services (as defined above).  

QRUR Information on Cost   

The QRUR identifies all the patients that are attributed to you and the totals all of the Medicare Parts A and B claims submitted by all providers who treated the patient.  The costs for care that was provided by other physicians will be linked to you if the patient has been attributed to you.     Outpatient prescription drug (Part D) costs are not included.  

The Cost Composite Score evaluates cost based on:

1) Per Capita Costs for All Attributed Beneficiaries

2) Per Capita Costs for Beneficiaries with Specific Conditions (diabetes, coronary artery disease, chronic obstructive pulmonary disease, and heart failure).  

It is important to note that if you do not have patients attributed to your practice or CMS is unable to calculate any of the cost measures because you have less than 20 cases, your cost score would be classified as ''average."   

QRUR Information on Quality   

The Quality Composite Score in the QRUR is based in part on the PQRS quality measures you reported.  Additionally, CMS will also calculate your performance on three outcome measures.  The outcomes measures include two composite measures of hospital admissions for ambulatory care-sensitive conditions (one for acute conditions and one for chronic conditions) and one measure of all-cause hospital readmissions. Your PQRS performance in addition to your performance on the outcomes measures will determine your quality score.     

3.  Be Aware of How CMS Will Evaluate Your Practice for the VBM and How You Measure Up Based on CMS Analysis   

Your QRUR will help you determine the potential impact of the VBM on your practice in 2017.  If you are a solo physician or have 2-9 practitioners in your practice AND you successfully participate in PQRS, you will receive an upward or neutral payment adjustment based on CMS' analysis.  If you are a solo physician or have 2-9 practitioners in your office AND you successfully participate in PQRS you are held harmless from any downward payment penalty in 2017.    You should also be aware that all comparative quality measures and cost data have been risk adjusted to account for differences in patient characteristics that might affect costs or quality outcomes. In addition, all comparative cost data are payment standardized to account for differences in Medicare payments across geographic regions due to differences in factors such as wages or rents.  

If you have questions please contact Kara Webb at:  

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