Michael McMurtry, M.D.
Cardiology, MACRA and structured reporting
March 31, 2017
By Dr. Michael McMurtry
With the issuance of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which replaced the Sustainable Growth Rate (SGR) and rolled multiple quality reporting programs into a single system, cardiology service lines are more dependent than ever on accurate and complete data capture. It’s a challenge with which many continue to struggle, and for which they have little time to overcome. Performance in the current year will be the basis upon which 2019 payments are adjusted. Those cardiologists and cardiology service lines that aren’t prepared with vastly improved reporting capabilities could potentially take a significant financial hit as penalties and bonuses phase in over time — starting with a bonus of up to 4 percent in 2019.
A MACRA/MIPS primer
MACRA includes two programs: The Meritbased Incentive Payment System (MIPS), which rolls together the Physician Quality Reporting System (PQRS), Value Modifier and the Electronic Health Record (EHR) Incentive Program and allows providers to earn payment adjustments by demonstrating the provision of high-quality, efficient care based on quality reporting, resource utilization, clinical practice improvement and advancing care information; and the Advanced Alternative Payment Model (Advanced APM), which lets providers earn greater incentives for providing high-quality, cost-efficient care by taking on some risk related to patient outcomes.
Most cardiologists are expected to participate in MIPS, under which they will be assessed based on performance against quality measures developed by the American College of Cardiology (ACC), American Heart Association (AHA) and other stakeholders. Part of its appeal is familiarity, as most of the quality measures under MIPS are currently reported under the PQRS. But the stakes are now much higher, with quality reporting counting as 60 percent of the provider’s MIPS composite score.
While MACRA/MIPS is currently front and center in discussions around quality reporting, the impact of accurate and comprehensive data capture and documentation goes much deeper for cardiology. A plethora of new mandates, harsher penalties and reimbursement opportunities — a more attractive Chronic Care Management program, increased penalties for preventable 30-day readmissions, the ongoing threat of RAC and other regulatory audits, cardiac bundled, Appropriate Use, etc. — have ratcheted up the pressure to adopt structured reporting.
Structured reporting plays a critical role in data integrity by driving comprehensive documentation. It helps ensure that every procedure report contains all the requisite data elements captured in standard formats and removes the variability that limits adoption of evidence-based practices that guide appropriate treatment. This allows information in the patient record to be queried to better understand treatments provided and identify any issues that may influence future care decisions, and helps clinicians determine if the care processes and protocols in place are appropriate — all of which leads to improved patient outcomes, enhanced compliance and more accurate coding for appropriate reimbursement.
Recouping millions
The impact of subpar documentation in the form of dictation or unstructured reports on coding alone can be millions of dollars for the average cardiology service. Consider the results of a recent study by Wolters Kluwer and MedAxiom Consulting exploring the relationship between facility and physician practices. A comparison of coding practices in 101 cases in five regional community hospitals revealed that half of physicians and slightly more than half of facilities coded incorrectly, resulting in significant risks of under- and over-billing.
Anecdotal evidence suggests that coding errors result from the methods employed to collect data post-procedure. Physicians typically dictate procedures verbally, which are then transcribed and sent back to the physician to review. Coders then turn those reports into CPT codes to submit for payment. Facilities have a similar procedure, documenting procedures as they happen and turning them into charges or codes that translate to APC codes which are then submitted for payment.
Wolters Kluwer, in partnership with MedAxiom, sought to quantify these suspicions by determining the accuracy of current coding practices in the cardiology setting. Researchers audited 101 procedure notes to compare the outpatient procedure documentation to the associated facility and physician professional service CPT codes selected for billing. A multi-state health care system provided five sites for analysis, each of which was asked to select two interventional cardiologists who performed both coronary interventions (PCI) and interventional peripheral vascular (PV) procedures. Five PCI cases and five PV cases were provided for each selected interventionist, for a total of 20 patient cases from each site.
Overall, coding was correct in approximately half of both PCI and PV cases, with 47.5 percent of facility cases and 50.5 percent of physician cases identified as accurate. In analyzing the data, MedAxiom determined that:
• The most common problems with physician coding were extra codes (13 percent), incorrect codes (10 percent) and missed codes (10 percent), while facilities recorded incorrect codes in 17 percent of cases, followed by extra codes at 16 percent.
• In PCI cases, physicians coded 73 percent correctly while facilities coded 53 percent correctly.
• In PV cases, facilities coded 42 percent correctly while physicians were correct just 28 percent of the time.
• Common facility PCI errors include incorrect codes (20 percent) and extra codes; for PV coding they were extra codes (20 percent) and incorrect code (14 percent).
• Common physician PV errors include incorrect code (16 percent), incorrect code plus extra code (16 percent), extra code (14 percent) and missed code (14 percent).
Further analysis by Wolters Kluwer suggested these errors put revenues in both settings at substantial risk. For studied facilities, over-billing of 6 percent for five sites put $795,000 at risk and could catch the eye of RAC and other regulatory auditors. Potential facility under-billing for those same five sites adds to lost revenue of $1.2 million.
For physicians, accurate procedure documentation remains the primary source of information in determining ongoing care for patients while also driving payments and allowing for effective cost-reporting. Researchers found that the potential cost of over-billing was $365,000 while under billing adds $881,000 to lost revenues. When the MACRA/MIPS performance-based penalties and bonuses, along with the cost of noncompliance with numerous other mandates, are added to the already high cost of inaccurate or ineffective procedure documentation used to support coding, the critical need to encourage adoption of structured reporting as a foundational best practice becomes clear.
Closing the gap
A primary reason why cardiology service lines and practices have yet to fully adopt structured reporting, despite issuance of a health policy statement defining the clinical standards for structured reporting in the cardiac catheterization suite, is a gap in technical capabilities that prevents automation of data capture, analysis and reporting. The cardiovascular information systems that are popular in these settings often lack the functionality, or are too labor intensive to keep current, to drive structured reporting by standardizing documentation based on industry best practices.
There are solutions available that can automate these processes and ensure data integrity. They work by guiding physicians along procedure-specific documentation paths and automating data capture and reporting, resulting in increased reporting efficiencies and a significant decrease in instances of human error that can lead to incomplete documentation and incorrect coding.
The intuitive documentation processes created by structured reporting software also allow many of the required quality elements to be collected directly from procedure notes, eliminating the need for duplicate data entry. Software interfaces are also capable of gathering information from devices and other IT systems, further streamlining quality reporting.
Here to stay
The role of quality reporting in cardiovascular services will continue to expand, impacting outcomes, compliance and revenues. By automating cumbersome and error-prone manual data capture, analysis and reporting through adoption of structured reporting, these organizations will benefit not only from streamlined compliance, but also from the improved clinical outcomes and solid financial footing that accompanies successful participation in MACRA/MIPS and a plethora of other performance-based initiatives.
About the author: Michael McMurtry, M.D., is director, clinical development & informatics for ProVation Medical, which is part of Wolters Kluwer. He manages medical content development and programs medical content for software used by physicians for procedure documentation and for coding to support reimbursement.
With the issuance of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which replaced the Sustainable Growth Rate (SGR) and rolled multiple quality reporting programs into a single system, cardiology service lines are more dependent than ever on accurate and complete data capture. It’s a challenge with which many continue to struggle, and for which they have little time to overcome. Performance in the current year will be the basis upon which 2019 payments are adjusted. Those cardiologists and cardiology service lines that aren’t prepared with vastly improved reporting capabilities could potentially take a significant financial hit as penalties and bonuses phase in over time — starting with a bonus of up to 4 percent in 2019.
A MACRA/MIPS primer
MACRA includes two programs: The Meritbased Incentive Payment System (MIPS), which rolls together the Physician Quality Reporting System (PQRS), Value Modifier and the Electronic Health Record (EHR) Incentive Program and allows providers to earn payment adjustments by demonstrating the provision of high-quality, efficient care based on quality reporting, resource utilization, clinical practice improvement and advancing care information; and the Advanced Alternative Payment Model (Advanced APM), which lets providers earn greater incentives for providing high-quality, cost-efficient care by taking on some risk related to patient outcomes.
Most cardiologists are expected to participate in MIPS, under which they will be assessed based on performance against quality measures developed by the American College of Cardiology (ACC), American Heart Association (AHA) and other stakeholders. Part of its appeal is familiarity, as most of the quality measures under MIPS are currently reported under the PQRS. But the stakes are now much higher, with quality reporting counting as 60 percent of the provider’s MIPS composite score.
While MACRA/MIPS is currently front and center in discussions around quality reporting, the impact of accurate and comprehensive data capture and documentation goes much deeper for cardiology. A plethora of new mandates, harsher penalties and reimbursement opportunities — a more attractive Chronic Care Management program, increased penalties for preventable 30-day readmissions, the ongoing threat of RAC and other regulatory audits, cardiac bundled, Appropriate Use, etc. — have ratcheted up the pressure to adopt structured reporting.
Structured reporting plays a critical role in data integrity by driving comprehensive documentation. It helps ensure that every procedure report contains all the requisite data elements captured in standard formats and removes the variability that limits adoption of evidence-based practices that guide appropriate treatment. This allows information in the patient record to be queried to better understand treatments provided and identify any issues that may influence future care decisions, and helps clinicians determine if the care processes and protocols in place are appropriate — all of which leads to improved patient outcomes, enhanced compliance and more accurate coding for appropriate reimbursement.
Recouping millions
The impact of subpar documentation in the form of dictation or unstructured reports on coding alone can be millions of dollars for the average cardiology service. Consider the results of a recent study by Wolters Kluwer and MedAxiom Consulting exploring the relationship between facility and physician practices. A comparison of coding practices in 101 cases in five regional community hospitals revealed that half of physicians and slightly more than half of facilities coded incorrectly, resulting in significant risks of under- and over-billing.
Anecdotal evidence suggests that coding errors result from the methods employed to collect data post-procedure. Physicians typically dictate procedures verbally, which are then transcribed and sent back to the physician to review. Coders then turn those reports into CPT codes to submit for payment. Facilities have a similar procedure, documenting procedures as they happen and turning them into charges or codes that translate to APC codes which are then submitted for payment.
Wolters Kluwer, in partnership with MedAxiom, sought to quantify these suspicions by determining the accuracy of current coding practices in the cardiology setting. Researchers audited 101 procedure notes to compare the outpatient procedure documentation to the associated facility and physician professional service CPT codes selected for billing. A multi-state health care system provided five sites for analysis, each of which was asked to select two interventional cardiologists who performed both coronary interventions (PCI) and interventional peripheral vascular (PV) procedures. Five PCI cases and five PV cases were provided for each selected interventionist, for a total of 20 patient cases from each site.
Overall, coding was correct in approximately half of both PCI and PV cases, with 47.5 percent of facility cases and 50.5 percent of physician cases identified as accurate. In analyzing the data, MedAxiom determined that:
• The most common problems with physician coding were extra codes (13 percent), incorrect codes (10 percent) and missed codes (10 percent), while facilities recorded incorrect codes in 17 percent of cases, followed by extra codes at 16 percent.
• In PCI cases, physicians coded 73 percent correctly while facilities coded 53 percent correctly.
• In PV cases, facilities coded 42 percent correctly while physicians were correct just 28 percent of the time.
• Common facility PCI errors include incorrect codes (20 percent) and extra codes; for PV coding they were extra codes (20 percent) and incorrect code (14 percent).
• Common physician PV errors include incorrect code (16 percent), incorrect code plus extra code (16 percent), extra code (14 percent) and missed code (14 percent).
Further analysis by Wolters Kluwer suggested these errors put revenues in both settings at substantial risk. For studied facilities, over-billing of 6 percent for five sites put $795,000 at risk and could catch the eye of RAC and other regulatory auditors. Potential facility under-billing for those same five sites adds to lost revenue of $1.2 million.
For physicians, accurate procedure documentation remains the primary source of information in determining ongoing care for patients while also driving payments and allowing for effective cost-reporting. Researchers found that the potential cost of over-billing was $365,000 while under billing adds $881,000 to lost revenues. When the MACRA/MIPS performance-based penalties and bonuses, along with the cost of noncompliance with numerous other mandates, are added to the already high cost of inaccurate or ineffective procedure documentation used to support coding, the critical need to encourage adoption of structured reporting as a foundational best practice becomes clear.
Closing the gap
A primary reason why cardiology service lines and practices have yet to fully adopt structured reporting, despite issuance of a health policy statement defining the clinical standards for structured reporting in the cardiac catheterization suite, is a gap in technical capabilities that prevents automation of data capture, analysis and reporting. The cardiovascular information systems that are popular in these settings often lack the functionality, or are too labor intensive to keep current, to drive structured reporting by standardizing documentation based on industry best practices.
There are solutions available that can automate these processes and ensure data integrity. They work by guiding physicians along procedure-specific documentation paths and automating data capture and reporting, resulting in increased reporting efficiencies and a significant decrease in instances of human error that can lead to incomplete documentation and incorrect coding.
The intuitive documentation processes created by structured reporting software also allow many of the required quality elements to be collected directly from procedure notes, eliminating the need for duplicate data entry. Software interfaces are also capable of gathering information from devices and other IT systems, further streamlining quality reporting.
Here to stay
The role of quality reporting in cardiovascular services will continue to expand, impacting outcomes, compliance and revenues. By automating cumbersome and error-prone manual data capture, analysis and reporting through adoption of structured reporting, these organizations will benefit not only from streamlined compliance, but also from the improved clinical outcomes and solid financial footing that accompanies successful participation in MACRA/MIPS and a plethora of other performance-based initiatives.
About the author: Michael McMurtry, M.D., is director, clinical development & informatics for ProVation Medical, which is part of Wolters Kluwer. He manages medical content development and programs medical content for software used by physicians for procedure documentation and for coding to support reimbursement.