1. Hess, Cathy Thomas BSN, RN, CWCN

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Welcome to the last Practice Points column in 2017! It has been quite a busy year integrating the new Merit-Based Incentive Payment System (MIPS). Let's look back at what we learned this year about MIPS and lean into using smart strategies in 2018.


Looking Back: MIPS and Your Workflow

Reviewing the Quality Payment Program,1 you earn a payment adjustment based on evidence-based and practice-specific quality data. Based on your performance in 2017, you will see a positive, neutral, or negative adjustment of up to 4% to your Medicare payments for covered professional services furnished in 2019. This adjustment percentage grows to a potential 9% in 2022 and beyond. In addition, during the first 6 payment years of the program (2019-2024), the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) allows for up to $500 million each year in additional positive adjustments for exceptional performance. In total, MACRA provides for up to $3 billion in additional positive adjustments to successful clinicians over 6 years. This Act replaced 3 Medicare reporting programs with Medicare Meaningful Use, the Physician Quality Reporting System, and the Value-Based Payment Modifier (MIPS). Under the combination of the previous programs, providers would have faced a negative payment adjustment as high as 9% total in 2019, but MACRA ended those programs, reduced the potential negative payment adjustments in the early years, and streamlined the overall requirements. The 3 reporting programs will finally be phased out in 2018, but if you have participated in these programs in the past, then you will have an advantage under MIPS because many of the requirements should be familiar.


If you are just starting to implement MIPS, be sure to verify your status online and work with your office or department to ensure you understand the configuration of your workflow and verify you have incorporated all documentation requirements to account for your Advancing Care Information, Improvement Activities, and Quality Measures (see the Practice Points columns from May and June, July, and September, respectively, available at Check your MIPS documentation progress often to verify requirements are being met in a timely manner. Last, remember that any change in processes can bring a welcome opportunity to review and refine documentation workflow(s) in general.


Leaning Forward: Regulations, Medical Necessity, and Audits

Each clinical staff member must understand the rules and regulations that guide the wound care department's documentation and billing processes. With so many regulations governing your work and documentation, it is important to have processes in place to ensure your documentation supports the rules, including medical necessity.


Stay abreast of the National Coverage Determinations and your specific Local Coverage Decisions (LCDs) for the latest information and guidance for coverage by the specific Medicare Administrative Contractor that processes the Medicare claims in your jurisdiction. Information for medical necessity can generally be found under the LCD section entitled: Coverage Indications, Limitations, and/or Medical Necessity. Be familiar with the managed care payer agreements and limitations.


Remembering to document medical necessity should be at the top of your mind at each patient encounter. Each service must prove to be reasonable and necessary to diagnose or treat a patient's medical condition. Further, the diagnosis code(s) reported (on the claim) with the service rendered is to justify (to a payer) why a service was performed. The diagnosis reported can be the determining factor in supporting or not supporting the medical necessity of the procedure.


Last, auditing your documentation should be a best practice initiative (see the October installment of this column for more information). Knowing the principles of medical record information provides the basis for performing an internal audit of the medical record.


That's a wrap on 2017. Wishing you a happy, healthy, productive, and successful 2018!




1. Centers for Medicare & Medicaid Services. The Quality Payment Program Overview Fact Sheet. Last accessed October 24, 2017. [Context Link]