TOA members are encouraged to turn to TOA’s e-mail newsletters for more information regarding MACRA.  TOA will also cover MACRA at TOA’s May 6, 2017 annual conference in Dallas.

Click here to view TOA’s October 31, 2016 webinar on MACRA implementation.

Click here to claim CME for participating in the webinar.

Cheat sheet for TOA Members coming soon.

Webinar Objectives:

  • Overview of the final rule and the elements that will be important for TOA practices to know for January 1, 2017.
  • In-depth analysis of each MIPS category and the requirements for the successful reporting requirements in a quick and easy manner.
  • Review of options available for reporting on Quality and Advancing Care Information measures, including how to effectively utilize the “Pick Your Pace” allowance.
Medicare Extends Site Neutral Policy in 2019 HOPD/ASC Payment Proposal; ASC Victories

A discussion related to approving hip and knee replacement surgeries for Medicare payment in ASCs dominated last year’s hospital outpatient department (HOPD) and ambulatory surgery center (ASC) payment proposal for Medicare. (Ultimately, CMS simply removed TKA from the inpatient only list.) The 2019 proposal, which was released on July 25, 2018, only addressed the anesthesia portion of TKA.

A new site neutral payment proposal that focuses on standard office visits (HCPCS code G0463) and potential new victories for ambulatory surgery centers (ASCs) have made the biggest headlines in the 2019 proposal. Under the 2019 proposal, the Ambulatory Surgery Center Association (ASCA) achieved most of its advocacy goals.

TOA members have been provided a lengthy proposal of the summary, which includes:

  • New site neutral payment provisions for clinic visits.
  • Removal of three pain communication questions, which will help with the opioid crisis.
  • A separate payment for Exparel in the ASC setting to address non-opioid pain management drugs.
  • The removal of the anesthesia-related code for TKA from the IPO list.
  • A lower device intensive procedure threshold proposal.
  • Progress on ASC payments and the market basket update.
Medicare’s 2019 Physician Fee Schedule and Quality Payment Program Proposal Released

The Centers for Medicare and Medicaid Services (CMS) released the calendar year 2019 payment rule for the Medicare Physician Fee Schedule (PFS) and Quality Payment Program for MACRA on July 13, 2018. Comments are due on September 10, 2018.

TOA’s members are invited to review TOA’s analysis of the proposal, which can be found in the e-mail newsletter or by visiting the website.

The following proposals relate to orthopaedics in the proposal:

  • Patient-reported outcomes for MIPS.
  • Checking the state’s prescription monitoring drug program (PDMP) database for MIPS.
  • Adding physical therapy to MIPS.
  • CMS believes that it will save the average physician 51 hours a year due to the new E/M proposal.
  • A small payment for “virtual visits” prior to an office visit.
  • Global data collection and its future. Hint: 90-day payments are big in orthopaedics.
  • Physician employment: Hospitals remain unhappy.

TOA Urges Lawmakers to Contact Congress on BPCI Advanced/CJR Conflict

BPCI Advanced – Medicare’s new physician-led bundled payment program that was announced in January 2018 – will not allow orthopaedic surgeons located in Texas’ five Comprehensive Center for Joint Replacement (CJR) to lead their own bundles for lower extremity joint replacements in the new BPCI Advanced program.

Due to the upcoming March 12, 2018 application deadline, TOA is encouraging TOA members in these CJR markets to contact their Members of Congress to contact the Centers for Medicare and Medicaid Services to allow orthopaedic surgeons to lead their own BPCI Advanced bundles in CJR markets.

The physician groups that have been participating in the existing BPCI Model 2 have demonstrated significant savings for Medicare. A study conducted by the largest BPCI physician group practice (PGP) convener of 15 private practice orthopaedic groups across the nation found that they saved Medicare $3,214 (15 percent) per LEJR episode in 2015 (compared to the 2009-2012 historic baseline data).

TOA has told Congress that patients and orthopaedic surgeons practicing in the CJR markets should not be penalized based on their geographic location.

Click here to view the sample letter.

Click here to view the CJR hospitals around the country.


IPAB and Physical Therapy Included in Congress’ Medicare Extender Package

The U.S. House and U.S. Senate approved a funding resolution on February 9 that includes several Medicare provisions that affect musculoskeletal care:

Physician-owned Hospitals:  No Relief. An effort by Texas lawmakers to allow physician-owned hospitals located in areas affected by the recent hurricane to expand by 50 percent was not included in the bill. However, Congressman Brian Babin of Texas is circulating a request for CMS to provide relief.

IPAB Elimination.  The Independent Payment Advisory Board (IPAB), which was created by the Affordable Care Act to address rising Medicare costs, was eliminated.

Physical Therapy’s Cap. Medicare’s existing “hard” physical therapy cap has been repealed (effective December 31, 2017).  However, it comes at a cost, and Congress relied on several offsets to help pay for it:

Explanation of the “New Cap” for Outpatient Medicare Part B

The threshold for targeted medical review will be lowered from $3,700 to $3,000 through 2027. However, not all claims that go over $3,000 will be subject to medical review. Instead, only a sample of the claims that meet certain criteria, such as high claims denial percentage or certain billing patterns, will be subject to the review.

The $3,000 per beneficiary applies to combined physical therapy and speech language pathology services – or $3,000 in occupational therapy claims alone.

Therapy claims for outpatient Medicare Part B that go over $2,010 (adjusted annually) will require the KX modifier for medical necessity.

Congress gave HHS the regulatory authority to address the manual medical review.

Physical Therapy Assistants Payment Reductions

The legislation will reduce payments to physical and occupational therapy services provided by a therapy assistant to 85 percent.  The payment reduction is scheduled to begin in January 2022 for outpatient therapy services.

The text of the therapy cap provision can be found on page 19. (Click here to view the bill’s language.)

Orthotist and Prosthetist Notes. Orthotist and prosthetist notes are now part of the medical record for purposes of Medicare medical necessity and claims audits.

Per the legislation:

13 Section 1834(h) of the Social Security Act (42 U.S.C. 1395m(h)) is amended by adding at the end the following new paragraph:”
(5) DOCUMENTATION CREATED BY ORTHOTISTS AND PROSTHETISTS. – For purposes of determining the reasonableness and medical necessity of orthotics and prosthetics, documentation created by an orthotist or prosthetist shall be considered part of the individual’s medical record to support documentation created by eligible professionals described in section 1848(k)(3)(B).”.

Stark Modernization. Commentary on the Stark laws begins on page 136 (click here). It exempts holdover lease arrangements and personal service arrangements from the definition of a prohibited compensation arrangement.

Meaningful Use. The bill contains parts of the Health Information Technology for Economic and Clinical Health Act by removing a mandate that meaningful use standards must evolve to be more stringent over time.

MIPS. The bill prohibits CMS from scoring an eligible clinician on improvement in the second, third, fourth, and fifth years (for which MIPS applies to payments).

Both the House and Senate bills block CMS from ever raising cost cutting to more than 30 percent of a physician’s scores.

Physician Fee Schedule. The updated will be reduced from 0.5 percent to 0.25 percent in 2019.

Medicare Announces New Bundled Payments

The Centers for Medicare and Medicaid Services (CMS) announced on January 9, 2018 that it is creating the voluntary Bundled Payments for Care Improvement Advanced (BPCI Advanced) demonstration that requires participants to take on financial risk. In addition, the program, which includes outpatient and inpatient episodes of care, would count as an Advanced APM for MACRA (Medicare’s physician payment program) for a 5 percent provider bonus.

Unfortunately, the proposal could have a harmful effect on markets that are affected by the Comprehensive Center for Joint Replacement (CJR) mandate. Those markets may not be able to participate in BPCI Advanced. Click here for full information.

TOA’s April 13-14, 2018 Annual Conference in Fort Worth will include a panel discussion on Medicare’s new bundled payment program.

Medicare-certified acute care hospitals and physician group practices (PGPs) may participate as either Convener Participants or Non-Convener Participants. The application ends on March 12, 2018. The next application period will not occur until January 1, 2020.

Some of the new program’s highlights include:

  • It will include a single payment and risk track. The original BPCI included four models.
  • The program begins on October 1, 2018 and runs through 2023, and it will include all participants to take on downside financial risk. Applications must be submitted by March 12, 2018.
  • For those who miss the initial application, a second application opportunity will open in 2020.
  • BPCI Advanced relies on a retrospective approach. CMS will provide a preliminary target price in advance of the first performance period of each model year prior to calculating a final target price retrospectively based on patient case-mix. The “CMS Discount” will subtract 3 percent from the benchmark that is based on historical fee-for-service spending.
  • As a result of BPCI Advanced not being a shared-savings initiative, participants can participate in this model and accountable care organizations (ACOs).
  • The episodes will last 90 days.
  • BPCI Advanced will qualify as an Advanced APM under MACRA beginning on October 1, 2018, which is the performance period’s effective date. On January 1, 2019, BPCI Advanced participation will result in a 5 percent APM incentive payment and the Qualifying APM Participant (QP) determination.

The CMS Innovation Center will hold a Q&A Open Forum on Tuesday, January 30, 2018 from 11 a.m. – 12 p.m. CST. This event is open to those who are interested in learning more about the model and how to apply. Please register in advance here.

Click here to learn more about the model.

Thirty-two types of clinical episodes will be included. Three outpatient episodes have been added to the inpatient episodes in the earlier BPCI model. Most of the episodes are found in the original BPCI model. However, an episode related to liver disorders is new.

For a list of the 29 Inpatient Clinical Episodes, please see below:

  • Disorders of the liver excluding malignancy, cirrhosis, alcoholic hepatitis *
    *(New episode added to BPCI Advanced)
  • Acute myocardial infarction
  • Back & neck except spinal fusion
  • Cardiac arrhythmia
  • Cardiac defibrillator
  • Cardiac valve
  • Cellulitis
  • Cervical spinal fusion
  • COPD, bronchitis, asthma
  • Combined anterior posterior spinal fusion
  • Congestive heart failure
  • Coronary artery bypass graft
  • Double joint replacement of the lower extremity
  • Fractures of the femur and hip or pelvis
  • Gastrointestinal hemorrhage
  • Gastrointestinal obstruction
  • Hip & femur procedures except major joint
  • Lower extremity/humerus procedure except hip, foot, femur
  • Major bowel procedure
  • Major joint replacement of the lower extremity
  • Major joint replacement of the upper extremity
  • Pacemaker
  • Percutaneous coronary intervention
  • Renal failure
  • Sepsis
  • Simple pneumonia and respiratory infections
  • Spinal fusion (non-cervical)
  • Stroke
  • Urinary tract infection

For a list of the 3 Outpatient Clinical Episodes, please see below:

  • Percutaneous Coronary Intervention (PCI)
  • Cardiac Defibrillator
  • Back & Neck except Spinal Fusion

Key Dates
March 12, 2018 – Application portal closes.

May 2018 – CMS distributes target prices.

June 2018 – CMS offers participant agreements.

August 2018 – Signed participant agreements are due.

October 1, 2018 – Model goes live.

March 31, 2019 – First date for Advanced Alternative Payment Model (APM) qualified participant determination.

January 1, 2020 – Next application period.

December 31, 2023 – End of the first cycle.


Medicare’s Removal from TKA from Inpatient-Only: Clarification

The Centers for Medicare and Medicaid Services (CMS) removed total knee arthroplasty from Medicare’s inpatient-only (IPO) list for the 2018 final rule. However, this does not mean that Medicare will pay for TKA in ambulatory surgery centers (ASCs).

The American Association of Orthopaedic Surgeons (AAOS) produced the following FAQs to answer questions. Click here to view it.

Click here to read TOA’s summary of the final rule.

Medicare’s Quality Payment Program Rule for Year 2 (MIPS/MACRA)

The Centers for Medicare and Medicaid Services (CMS) released the final rule for the Quality Payment Program’s second year on November 2, 2017.

Click here for an extensive overview of the rule.

Click here for an executive summary of the rule:


Among the highlights:

From 90 Days to a Full Year
Physicians will be required to report quality measures for a full year.  The current standard is a 90-day period.

Cost Counts for MIPS
A physician’s Merit-based Incentive Payment System (MIPS) score is made up of four categories: quality, cost, improvement, and Advancing Care Information (ACI), which takes into account the use of EHRs.

Next year, CMS will count performance on cost measures for 10 percent of a physician’s score, even though CMS indicated earlier that it would delay factoring cost into a physician’s score for 2018.

CMS stated that it will use the Medicare spending beneficiary and total per-capital cost measures to calculate the cost performance category score for the 2018 MIPS performance period. Physicians will not be required to take any action because CMS will calculate the scores. The two measures carry over from the Value Modifier program.

The agency said that is developing new episode-based measures on cost with stakeholder input and soliciting feedback on some of those measures in the fall of 2018. CMS also said that it expects to propose new cost measures in future rules and solicit feedback on episode-based measures before they are included in MIPS.

Certified EHRs
The rule will allow physicians to use 2014 edition and/or 2015-certified HER technology in year two of the ACI performance category. A performance will be given for using only 2015 CEHRT.

Low-volume Threshold Exception
Physicians were excluded in 2017 if the practice had no more than $30,000 in Part B charges or saw no more than 100 beneficiaries in a year. For 2018, physicians will be excluded if they have no more than $90,000 in Part B charges or see no more than 200 beneficiaries.

Small practices that do participate in MIPS will be provided five bonus points.  Solo and small practices will also have the opportunity to form virtual groups.

Alternative Payment Models (APMs)
As we have stated in the past, not too many orthopaedic services qualify for the Advanced APM portion of MACRA.  As a result, most orthopaedic surgeons are focusing on the MIPS portion for MACRA.

CMS has hinted in the past that it would like to create more opportunities for surgeons to participate in an Advanced APM.  As a result, we are expecting CMS to announce new physician-led bundled payment models in the near future.  Hospital-led bundled payments typically do not qualify as Advanced APMs.

There is extensive commentary regarding APMs in the rule.  For example, CMS indicated that it plans to develop a demonstration project to look at how physicians participating in Medicare Advantage alternative pay models can qualify for bonus payments.

Twenty-one New Improvement Activities
CMS stated:

In this final rule with comment period, we are finalizing updates to the Improvement Activities Inventor. Specifically, as discussed in the appendices (Tables F and G) of this final rule with comment period, we are finalizing 21 new improvement activities (some with modification) and changes to 27 previously adopted improvement activities(some with modification and including 1 removal) for the Quality Payment Program Year 2 and future years (2018 MIPS performance period and future years)Improvement Activities Inventory.

CMS Announces New Direction for CMMI

CMS announced a request for information regarding the future direction of the CMS Innovation Center.

The Texas Orthopaedic Association will be providing comments regarding solutions for enhancing muculoskeletal in the Medicare program.

Per CMS:

In partnership with clinicians, patients, entrepreneurs, state officials, and others, the Centers for Medicare & Medicaid Services (CMS) plays a leading role in safeguarding the health of America’s future by providing coverage to over 130 million Americans, more than a third of the population of the United States. Our nation’s elderly and most vulnerable citizens depend on these programs for access to care but both programs face fiscal crises. Medicare’s main trust fund is projected to run out in just eleven years, and Medicaid is the second largest budget item for states on average (behind K-12 education) and is growing rapidly. Improving quality and reducing costs are imperative.

One of the most important goals at CMS is fostering an affordable, accessible healthcare system that puts patients first. Through this informal Request for Information (RFI) the CMS Innovation Center (Innovation Center) is seeking your feedback on a new direction to promote patient-centered care and test market-driven reforms that empower beneficiaries as consumers, provide price transparency, increase choices and competition to drive quality, reduce costs, and improve outcomes. The Innovation Center welcomes stakeholder input on the ideas included here, on additional ideas and concepts, and on the future direction of the Innovation Center. In particular, the Innovation Center is interested in testing models in the following eight focus areas:

  1. Increased participation in Advanced Alternative Payment Models (APMs);
  2. Consumer-Directed Care & Market-Based Innovation Models;
  3. Physician Specialty Models;
  4. Prescription Drug Models;
  5. Medicare Advantage (MA) Innovation Models;
  6. State-Based and Local Innovation, including Medicaid-focused Models;
  7. Mental and Behavioral Health Models; and
  8. Program Integrity.

However, the Innovation Center may also test models in other areas.

To be assured consideration, please submit comments online or by email to through 11:59 p.m. EST November 20, 2017.