Value-based Modifier (Adjustment)

Date: October 28, 2014

Is your group comprised of 10 or more providers? If so, your group will be subject to the value modifier in 2016, based on your performance in calendar year 2014. All providers will be subject to the value modifier in 2017 based on their performance in calendar year 2015.

What is the VB Modifier?

Section 3007 of the Affordable Care Act mandated that, by 2015, CMS begin applying a value modifier under the Medicare Physician Fee Schedule (MPFS). It provides for a differential payment (higher or lower) under the MPFS based on the quality of care provided when compared to the cost of the care.

The “quality of care” component is a direct link to the PQRS program. In order to be successful with the VBM and avoid a negative adjustment, physicians and/or groups must report successfully under the PQRS program.

Penalties

Groups that are 10 or more eligible professionals in 2014 that do not successfully report PQRS for 2014 will see a 2% VBM reduction in their 2016 Medicare payments.

According to the CMS website, Groups of 10 or more EPs can avoid the automatic “-2.0%” Value Modifier payment adjustment in CY 2016 by participating in the PQRS Group Practice Reporting Option (GPRO) in CY 2014 and meets the satisfactory reporting criteria to avoid the “-2.0%” CY 2016 PQRS payment adjustment.” orGroups with 10 or more EPs can avoid the automatic “-2.0%” Value Modifier payment adjustment in CY 2016, if the EPs in each group participate in the PQRS as individuals in CY 2014 and at least 50% of the EPs in each group meet the satisfactory reporting criteria as individuals (or in lieu of satisfactory reporting, satisfactorily participate in a Qualified Clinical Data Registry) to avoid the “-2.0%” CY 2016 PQRS payment adjustment.”

The VBM program is very complex, especially the calculation associated with the cost measures and the methodology for calculation. Expect more details in the coming months.

Additional information regarding the VBM can be found at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Background.html

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 ...