CMS Proposes Changes to Potential Penalties for 2016 PQRS and VBPM

Date: July 19, 2017

Late on Friday, July 14, 2017, CMS released the Proposed 2018 Medicare Physician Fee Schedule (MPFS).  It will be published in the Federal Register on July 21, 2017.  It contains some provisions of interest to practices who might incur penalties from 2016 reporting for either PQRS or VBPM.  The recent release is important because, although MIPS (the Merit-based Incentive Payment System) is currently in effect for 2017, the reporting your practice did in 2016 affects your 2018 payments.  If you were slated to incur a penalty under either or both of these programs in 2018, this may help alleviate the severity of the penalties.

The 2016 PQRS program policy required providers to report 9 measures across 3 National Quality Strategy domains.  The proposal from CMS retroactively changes this to require success in only 6 PQRS measures.

If you successfully reported fewer than 9 PQRS measures, or had 9 but they fell into fewer than 3 National Quality Strategy (NQS) domains, then you were slated to receive a 2% PQRS penalty and a VBPM penalty of either 2% or 4% (for a total reduction to your 2018 MPFS of either 4% or 6%), depending on your practice size.

PQRS:  This proposal would allow those who fell only slightly short to incur no PQRS penalty.  For example, the below are examples of “falling just short”:

  • You reported successfully on only 6-8 PQRS measures
  • Reported 9 PQRS measures successfully but had only 1 or 2 NQS domains

VBPM:  This proposal would decrease the size-based of 2% or 4 % penalty on VBPM to the following:

  • If you are a group of 10 or more providers, your potential penalty would shrink from 4% to 2%
  • If you are a solo provider or in a group of 2 to 9 providers, your 2% potential penalty would go down to 1%

If you need help with anything related to the above or with coding, documentation, or ophthalmic practice management, Corcoran Consulting Group can help.

Recent News

CMS Extends Deadline for MIPS 2023 Data Submission

CMS has extended the data submission period for the Merit-based Incentive Payment System (MIPS) eligible clinicians who participated in the 2023 performance year of the ...

Congress Passed bill for MPFS

The recent passing of a partial government funding bill by Congress on March 8 is important to Medicare beneficiaries. This bill includes policies aimed at addressing ...

Change to Processing for Telehealth Services Billed with POS 10

In calendar year (CY) 2024, the Centers for Medicare & Medicaid Services (CMS) issued a change to processing for telehealth services billed with POS 10. ...

Diabetes Cost Measure Misattributed to Ophthalmologists

The American Society of Cataract and Refractive Surgery (ASCRS), the American Society of Retina Specialists (ASRS) and the American Academy of Ophthalmology (AAO), met recently ...

Review Your 2022 MIPS Performance Feedback and Final Scores

The Centers for Medicare & Medicaid Services (CMS) has released the Merit-Based Incentive Payment System (MIPS) performance feedback and final scores for the 2022 performance ...

JZ Modifier Required July 1, 2023

The much-anticipated mandatory reporting of the JZ modifier for Part B Medicare begins July 1, 2023.  The new Medicare policy can be found here.  The ...

Cigna Hits the Brakes on Their New Modifier 25 Policy

Following fierce opposition from the physician community, the insurer Cigna announced today a delay in implementing a policy (PDF) that would have required submitting medical ...

Medical Consulting Group and Corcoran Consulting Group Announce Merger

Springfield, MO, April 27th, 2023. Medical Consulting Group (MCG), a provider of consulting services to ophthalmic practices and companies, and Corcoran Consulting Group (CCG), a ...

IHEEZO Gel gains Medicare Pass-Through

On March 13, 2023, Harrow® announced that the Centers for Medicare & Medicaid Services (CMS) has approved transitional pass-through reimbursement status for chloroprocaine hydrochloride ophthalmic ...

Cigna Change Modifier 25 Policy

As a result of a recent review, Cigna has announced it will require the submission of office notes with claims submitted for evaluation and management ...

Congress makes positive adjustments that affect ophthalmologists

In this Healio Video Perspective from Hawaiian Eye 2023, Kevin J. Corcoran, COE, CPC, CPMA, FNAO, discusses ophthalmic economic and regulatory updates for the year. ...

HHS Extends Covid-19 PHE

On Thursday, October 13, the U.S. Department of Health & Human Services (HHS) Secretary Xavier Becerra extended the nation's COVID-19 PHE for an additional 90 ...

Noridian Changes to Goniotomy LCD

Noridian has made changes to their Goniotomy coverage policy effective October 1st, 2022. It states: “Since there is no specific CPT® code for goniopuncture or ...

2021 MIPS Performance Feedback, 2021 MIPS Final Score, and 2023 MIPS Payment Adjustment Information

The Centers for Medicare & Medicare Services (CMS) has released Merit-based Incentive Payment System (MIPS) performance feedback and final scores for the 2021 performance year, ...

Telehealth Place of Service Update

With a recent change to telehealth billing, billers need to be aware of an additional Place of Service code. What changed? Effective January 1, 2022, ...

Extension of Telehealth Flexibility

Last week, the U.S. House of Representatives approved legislation to further extend the Medicare telehealth flexibilities first instituted in response to the COVID-19 pandemic. If ...

AETNA No Longer Requiring Prior Authorization for Cataract Surgery

The American Society of Cataract and Refractive Surgery (ASCRS) and American Academy of Ophthalmology (AAO) have spearheaded a year-long effort to remove the policy that ...

2021 MIPS Final Score Preview Now Available

The Centers for Medicare & Medicaid Services (CMS) has opened the Final Score Preview period for the Merit-based Incentive Payment System (MIPS).  You can now ...

Guidance for Coding Goniotomy

Summary:   Two new ophthalmic surgical products have attracted interest from surgeons:  Streamline Viscoelastic Injector® (New World Medical) and IACCESS™ trabecular trephine (Glaukos).  In both cases, ...

CIGNA Changes Their Modifier 25 Policy

As a result of a recent review, CIGNA will require the submission of office notes with all claims submitted with evaluation and management (E/M) CPT ...

CMS Reweights Scoring for Cost Category for Groups in 2021 Quality Payment Program

The Centers for Medicare & Medicaid Services (CMS) announced on Monday, April 25th, that ALL eligible MIPS providers will automatically receive re-weighting of the Cost ...

IACCESS™ Trabecular Trephine – How to Code?

Summary:   Glaukos’ new product, the IACCESS™ trabecular trephine, raises interesting coding questions.  Standalone procedures should be reported on a claim for reimbursement as unlisted procedure, ...

Streamline® Viscoelastic Injector – How to Code?

Summary:   New World Medical’s new product, the Streamline® Viscoelastic Injector, raises interesting coding questions.  Standalone procedures with it should be reported on a claim for ...

HHS Extends the Public Health Emergency Waivers

On April 12, 2022, Secretary of Health and Human Services Xavier Becerra again renewed the public health emergency declaration that was initiated at the end ...