Understanding How MACRA and MIPS Make Documentation Matter Even More

Discover why your success in this QPP track depends on documenting.

You probably don’t need to be told Medicare physician reimbursement is currently seeing, as Modern Healthcare put it, “its biggest change since its launch in 1965.” To avoid financial penalty, approximately 622,000 U.S. clinicians (as estimated in CMS’ final rule about the program) must now participate in the Quality Payment Program CMS established to implement MACRA, the Medicare Access and Children’s Health Insurance Program (CHIP) Reauthorization Act of 2015.

What you might need is help understanding how MACRA, MIPS, APMs, bundled payments and other efforts to “drive the [U.S.] health care system towards greater value-based purchasing” affect your practice. As the U.S. healthcare system’s shift away from fee-for-service reimbursement gathers speed, it’s only natural providers have concerns and questions. MACRA is particularly far-reaching and complex. “Meaningful use is first-grade arithmetic,” Healthcare IT consultant Dan Golder told Modern Healthcare, referring to a familiar EHR incentive program MACRA is sunsetting, “and MIPS and MACRA are college-level calculus… The complexity of MIPS is going to be very difficult for physicians to stomach.”

MDCodePro specializes in helping practitioners increase their coding accuracy, regulatory compliance, and profitability. As we noted in our discussion of new U.S. tax law, we don’t presume to present expert legal or financial advice. But while we can’t offer a comprehensive review of MACRA’s many provisions (the final ruling runs 1,653 pages, Healthcare Informatics reports,) we can help you refresh your understanding of MACRA’s basics and point out some of its impact on how you document the services you provide your patients, because documentation is always key in optimal coding.

A Summary of MACRA MIPS and APMs

MACRA uses a two-track Quality Payment Program (QPP) to reward practitioners for quality care delivered to Medicare beneficiaries:

  • understanding macra mipsThe Merit-Based Incentive Payment System (MIPS) consolidates current pay-for-performance programs and determines payment bonuses, penalties, and adjustments based on providers’ scores in four categories: quality, resource use, clinical practice improvement activities, and meaningful use of certified EHRs. Providers have the flexibility of choosing the MACRA MIPS quality measures most appropriate to their practices.
  • Advanced Alternative Payment Models (APMs) incentivize high-quality, cost-effective care by exempting qualifying participants from MIPS reporting requirements and payment adjustments.

The existence of “MIPS APMs” complicates the QPP’s two-track structure somewhat; however, according to CMS, “[m]ost Advanced APMs are also MIPS APMs.” Most clinicians will participate in the MIPS track. Clinicians or groups serving 200 or fewer Medicare Part B beneficiaries or who have billed $90,000 or less to Medicare are exempt.  

Checking your participation status is vital. (You can do so here.) Penalties for eligible practitioners who aren’t participating will reach as much as 9% by 2022, while participant rewards will climb equally as high.

Why MIPS Demands You Increase Attention to Documentation

MACRA will impact medical coding in a very practical way because, in some cases, it necessitates new codes. For example, because the law aims to improve coordination of care among providers across specialties and settings, it requires CMS develop new codes for identifying episodes of care and patient condition groups, plus group classification codes.

But any understanding of MACRA and MIPS that doesn’t consider the law’s implications for documentation, so foundational to sound coding, would be incomplete. “It’s important to remember,” write Kathryn DeVault and colleagues for AHIMA, “that accurate documentation and complete and compliant coding impacts almost all areas of quality reporting and, ultimately, provider reimbursement.”

Writing for the AAPC, billing and coding expert and instructor Rhonda Buckholtz makes MIPS’ stakes clear: “MIPS starts in 2019 with 4 percent on the line…That could add up to over $200,000 for even smallish practices. Who couldn’t use that much extra revenue in their practice? Which one of us can afford to lose that much?”

Dedicate Yourself to Improved Documentation with MDCodePro

As part of your adjustment to MACRA, then, decide to make your medical coding as strong as possible with MDCodePro.

Our methodology, which has been validated in repeated audits, equips you to document each patient visit to support its optimal CPT® code. Our short series of video lectures streamline CMS’ complicated coding regulations into a manageable and memorable system you can put into practice right away. And our easy-to-use code generator uses the data you give it to identify the code ensuring your greatest accuracy, regulatory compliance, and legitimate reimbursement.

Don’t let weak documentation keep you from full compliance with MACRA or the revenue to which you’re entitled under the new law. Sign up for MDCodePro today.

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