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AAPC CPC Prep Course - Chap 1 Summary
Notes
c PC Course — Chap 1 Notes: The Bu inoss of Medicine oding as a Profossion Modical Coding — precess of translating a healthcare provider’ $ documentation of a pationt on unter inte a series of numeric or alphanumeric codes | services 0 Separate code sets to describe diagnoses, medival and surgi procedure: supplies 0 Universal shorthand language to: § Ease data collection © Evaluate quality of § Determing costs and reimbursement Coding Sy mbulacary settin 0 CPT. HCPCS Level I, ICD-10-CM. © Coding lies direclly Io reimbursement — codes must he assigned correctly Lo ensure proper s, provider offi 3. long-term payment odo assignment — determined by provider’ s documentation and unique rules thar govern cach code set 0 Vary depending en who is paying for pationt’ s sare, Medical Care is complox and variable — as are coding requirements. 0 Provise coding —requires a thorough undarstanding of coding guidelines, mastery of anatomy and modical terminology 0 Must be detailed oriented eos ineonpl 2 - will cot uracslace prepecly co ube pravites’ s facumertalion is iagceu langeage of cases > wil ror get propery reimbersement 0 Mus § Evaluate the documentation for completenoss and accuracy © Communicate regularly with the physician to ensure documentation requirements ot by payers are met 0 May use computer programs to tabulate and analyze data to improve: § Patientcare § Better control costs a Provide documentation for use in legal actions, or use in research surdies Coders who specialize in inpatient coding are referred to as health information coders, medical recard coders oderfabstrad or coding spacialists 0 Assigna code to cach diagnos: 4 procedure documented 1 Rely on their knowledge of discase processes ° Coders then u ification system software to assign the pationt to one of the several hundred Related Groups (MS-DRG) 8 MS-DRG determing the amount of hespital will be reimbursed if the patient is covered Medicare Severity—Diagnos by Medicare or other insurance progi ams using the MS—DRG system Coders can als » specialize in Cancer registry 0 ancor registrars maintain facility, regional, «nd national databases of cancer patients 0 Review patient records and pathology reports to assign codas for the diagnosis and trearment of different cancers and select benign tumors 0 Condu tot nnual follow-ups on all patients in the registr ick treatment, recovery, and survival 0 Caleulate survival raves of various treatments, locate geographic arcas with high incidences of cortain cancers, and identify potential participants for clinical drug trials Continuing Education — very essential for coders 9 Codes and policies can change quarterly # Adoption of EHR — broaden and alter coders’ responsibilities 0 — Must be familiar with EHR software 0 Maintaining security 0 An zing electronic data to improve healthcare information sist in improving EHR software and contribute te the development and maintenance of health information networks o «Take on auditing role in reviewing EHR code suggestions based on documentation © Coding is a tochnical and rapidly changing ficld 0) Skilled caders may become — consullants, educalors. medical atklilors 0 Evolved over the past several decades and will continue te da so iT As hoalthvare embraces new technologies. cade sets and payment methodologies The Difference Between Haspital and Provider Services © Outpatient « o Outpatient coders use CPT, HCPCS Level If and IGD-10-CM 0 Work in provider offices, outpatient clinics, f ding — pertains to provider services acility outpatient departments © Outpatient fa ouse Ambulatory Payment Classifications (APC. 0 Have more interaction with providers throughout the day ¢ Inpatient coding 0 Use IOD-10-CM and ICT—10-PC Also use MS—DRGs for reimbursement codes direct interaction with providers Uow Provider Oifice Works and Tow the coder Fis @ Patiert visits the mecic isc + front desk gersen ehtains ‘nscraqece are nagraphics (ar informa > inf joa is clestrarica ly o3za‘ns before ¥ ig entered irte 2 menage ert syscen > provider sees the patiert + pr cwencs vist in pation? medisal reced ard completes enecerter ‘srm > at completion of visic, xetiert cheeks sus and pe copay 1 applcasle s IGP T 1s tris irtermatiar ig sakwitted on a claim oa ©) After petert leaves office + ¢scamertetion is cranslatec into prscecurs or sepaly ex S) and iagnesis coges UID= 19- the insurance compary ov payer to obtain reimbursemert 0 This translation of documented information from the visit is referred te coding: © — Cading — can be reformed by provider, EHR. or Coder &— Whon the provider or EHR performs the coding, the coder takes over the role of auditor to verify the documentation supports the codes selected 1 Whon the coder performs the coding, the coder reviews the provider’ s documentation and codes the services based on what is documented in the pationts records . After the covumencacor is trarslated to cages > they are assign a fee and bil pationt o> payer 0 The place of service cade is reported to indicate where services were performed © These are found in lhe CPT cade book o Thee formats) rges are billed to payer using the CMS— 1200 claim form (available in both paper & digital & Many payers now only accept electronic claims: 1 Medically necessary provider services — need to diagnose or treat and that meet cepted 1 Preventive services — prevent illness, detect illness at an ge 1 Medivare Part B is an optional benefit for which the patient arly § pays a monthly premium, «mual deductible, 20% co—insurance. oxcopt for preventive services covered under healthcare Taw 0 Medicare Part C — Also Called Medicare Advantage ' Combines henafits of Part A & Band semetimes Part D 1 Plans are managed by private insurers approved hy Medicare and may include PPOs, HMOs or others: # Plans may charge different Ss, coINSUTANce ar deductibles for services: & THO CMS Hierarchical condition category (CMS-HCC) risk adinstment model provides adjusted payments based ona patient’ s diagnosis and co-morbidities # Thora may be loss of additional reimbursement to which the provider is ontitled 9 Medicare Part 2 — prescription drug program available to all Medicare beneficiaries for a for a Pri coverage ¢ companies approved by Madicare provide the ' Medicaid — health insurance assistance program sponsored by federal and state goveraments for lw—income peuple (including children and pregnanl women) . Adwiristered on a state-by stare bases > cov age varies 0 Though each stare adheres te certain federal guidelines © Statefunded insurance programs that provide coverage for children up to 21 inchide: Children’ s Medical Services, Children’ s Indigent Disability Services, Children with Special Meallhcare Needs # program s aro designed for henoficiaries with specific chronic medical conditions, . Each provider must decide whether to contract with private insurance carriers: or government programs 0 Wher eercrasced wth the insuraase carrion provider is cersideree a “participate pravicer’ fyarpravdesd © Required to accept the allowed payment amount determined by the insurance carrier as foo for payment. and follow all other guidelines in contract a The difference between the provider’ s fee insurance carrior’ allowed amount is adjusted by the participating provider Non—participating provider (not contracted) is not required te make adjustment 1 Por Medicare services, even is a provider is non—participating — sel limits on what the ‘The Medical Record patient can be charged — referred to as a limiting charge . Medical record — provider’ s documentation of pertinent fa ions about a patient’ s health history, including 0 Past & present illnosses 0 Tosts 0 Treatments 0 Outcomes © Chronologically documents patient care to assists in the continuity of care botweon providers facilitate claims review and payment & serve as a legal document 0 All services provided to a patient are documented in the medical record 0 Administrative data (ex: financial records. should not be included in the medical record or provided in response to a subpoona or request for medical records # EHRs are slowly replacing 0 his relatively new technology creates oppertunity for both improved efficie heightened compliance risks Evaluation and Management Documentation 6 E/N sory SOAP notes: ihicetive — the patient’ s statement about his or hor health, including symptoms re often provided ina standard format such 0 O= Objective — the provider’ s¢xamination and documentation of the patient’ illness using obser ition, palpation, auscultation, and percussion 8 Tests and other services performed may be documented here as well 0 A— Ass 1 This is usually whore you find the diagnosis (es) that supports the services ssment — Evaluation «and conclusion made by the provider rendered 0 P= Plan - whother it’ s ordering additional tests. taking over—the-countar medications, ote surse of action, Hore the provider will list the next staps far the patient. © Not all E/M documentation is written ina clear SOAP format, but cach chart must contain the required components of the visit assoviated with the code(s) billed Operative Repart Documentation © Operative reports are used to documant the de of a procedure performed on a patient 9 Most aperative notes have a header and a body in the report © The header should include: © Date and time of the procedure # Names of the surgeon, co—surgoon, assistant surgeon ¢ Type of anesthasia and anesthesia provider name © Preoperative and postoperative diagnosis © Provedure performed complications & The bedy should include: . Indi ion for surgery Details of lhe procedure(s) * Findings 0 Approximately 20% of an opel ontains words thar are los coder as impertant to, ative report they are not needed to repart the services er procedures iT A coder is tasked with breaking down the info and applying o st codes: re @ Operative Report Coding Tips! h for understanding oO Highlight unfamiliar words — reses © Diagnosis code reporting — use the pos dofined diagnoses or additional diagnoses found in the body of the oper: operative diagnosis for coding unless there are furthor tive repert. with CMS when Appropriate, based on the law, regulations, rulings. and general program instructions” © Pract ces should check polivies quarterly to maintain compliance ¢ The LCD explains when Lhe service is indicaled or necessary and identilies limitations on coverage . There may also be documentation guidelines associated with the LCD. 0 This section should be checked to determine if additional information is required te be sent on or with the claim form for the service to he covered, or if specific results are required in the documentation 0 This sc so idontifios if there is ana ciated billing and coding article . LCDs o provide a revision history to identify when and what changes were made to the LOD MA an LCD to make the following information available on its website and the medicare website 45 days before # The 2016 21st Contury Cures Act made changes to the LCI process and requires o that develops the effective date: 0 The determination in its ontirety 0 — Where and when the proposed determination was first made public 0 — Hyperlinks to the proposed determination and a response to comments submitted to the contractor with respect te such proposed determination 0 The summary of evidence that was considered by the contractor during the development of such determination and a list of the sources of such evidence 0 Ancxplanation of the rationale that supports such determination © The Act als are linked to the LCD » requires MACs to remove all codes from LCDs and place them in billing and coding articles that 0 These articles can ke found on the MACs website or on the Medicare Coverage Database 0 The articles contain the coverage guidance, specific CPT and [CD-10-CM codes. Bill Type codes, and Revenue codes, in addition to codes the ty are specifically noted as not supported by medical nec If youare providing a service and Lhe Medicare patient” s diagnosis doesn’ | support lhe medical necessity requirements per the 1 and billing and coding article, the service may not be covered 9 Insuch a case, the practice would be responsible for obtaining an Advance Bonoficiary Notice of ge (Ad il (non-Modicare) payors may develop their awn medical polivies. which do not Noncover -¢ Banefiviary Notice or ABN) ¢ Commerc nee ssarily follaw Medicare guidelines 0 They may be specified in private contracts between the payer and the practice or provider or referenced in provider manuals found on the payer’ s website 9 — Caders need to be aware of the contract requirements of the individual commercial payers wto which they submit claims The Advance Beneliciary Nolice . co honefi iarigs and providers have certain rights «and protections related to fi incial liability o © These finar liability and appeal rights d protections are communicated to benoficiarios through notices given by providers # Providers should use an Advance Bonofiviary Notice (ABN) whon a Medicare honoficiary requests or agrees te receive a procedure or sorvive that Modivare may not cover 0 The ABN is a standardized form that explains to the pationt why Medicare may deny the service or provedure 0 ABN protects the provider’ s financial interest by creating a paper trail that CMS requires befere a provider can bill the pationt for payment if Medicare denies «: verage for the service or procedure «Providers must complete the ong—page form in full, giving the patient an explanation as to why Medicare ig likely vo refuse coverage for the propesed procedure er service © Common reasons Medicare may deny a procedure or service include = Medicare doesn’ t pay for the procedure/service for the pationt’ s condition n Medi 1 Medicare doesn’ 1 pay for experimental procedures/services wedoesn’ t pay for the precedure/service s frequent 18 proposed # The standards for use of the ABN are listed in Section 50 of the Medicare Claims Processing Manual 0 This quick guide is an abbroviated reference tool and is not meant te replace er supersede any of the directives contained in Section 50 © The explanation of why Medicare may deny tho service or procedure should be as specific as possible 0 A simple statement that Medicare may not cover this procedure is not sufficient, and ABNs may not be given to all Medicare patients routinely ¢ The provider must present the patient with a cost estimate for the proposed procedure or service 0 CMS ir ostimate:+ the estimate should be within $100 or 25% of the actual costs, whichavor ig greater” 0 Medi s the beneficiary “would not be harmed if the actual costs wore less than predicted” structions stipulate, “Notifies sonable nust make a good faith effort to ins arta red allows an estimate that substantially exceeds the actual costs $ rules require the provider te present the ABN “far enough in advance that the beneficiary or representative hag time to consider the eptions and make an informed choice” 0 The ABN “must be verbally reviewed with the benefici ry or hig or her representative and any questions raised during that review must be answered” bofere the patient signs the ABN «When ABN pre s completed ancl reviewed in full, lhe Medicare beneficiary may choose Lo proceed with the cedure/ ‘sorvice and assume financial responsi bility or may glect to forego the procedure or service 0 Ifpationt chooses to proceed. he or she may request the charge be submitted to Medicare for consideration Gvith underst 0 Ag provider must retain the original notice on file anding that it will probably be denied) copy of the completed, signed form must be given to the beneficiary ar representative, and the © The pationt’ s signature is not required for assignod chtims (that is, claims submitted by and paid to a hoaltheare provider on behalf of the beneficiary) 0 Ifthe benefic procedure or service, the provider should document the patient’ s refusal ary refuses to sign 1 properly presented ABN, but still requests the 0) The provider and a wiln should Lhen sign Lhe form. # Inthe case of unassignad claims Gyhon claims are submitted by the provider but the payment is sent to the patient who then reimburses the healthcare provider). a signature is required on the ABN to hold the patient financially Wable 0 If the patient refuses to sign, the only options are not to provide the service or procedure (which might raise potential nogligance issues) or te provide the service with the understanding thar the provider may not be able to recoup payment from either Medicare or the beneficiary . An ABN should not be used to bill the beneficiary for additional fees beyond what Medicare reimburses for a given procedure ar service 0 Coverage issued as a supplement to liability insurance © Liability insurance, including general liability insurance and automobile liability insurance 0 Workers’ compensation or similar insurance 0 Automobile medical ment Insurance 0 Credit-only insurance 0 — Coverage for on-site medical clinics 0 Other similar insurance coverage, specified in regulations, under which benefits for medical care are secondary or incidental to other insurance benefits 0 A healtheare o) dard health information saringhouse: this includes entities that process nons they receive from another entity into a standard formar (such as a standard electronic format or data content) or vie vers © The logislation also required the establishment of a national Healthcare Fraud and Abuse Control Program (HCFAC), under the joint direction of tho attorney general and the secretary of HHS, acting through the department’ s inspector general 9 The HCPAC program is designed to coordinate, federal, state. and locall law enforcement activitios with respect to healthcare frand and abuse The Nood for National Standards for Electronic Healthcare Transactions and Code Sots © CUMS states “transactions are electronic ¢ changes involving the transfer of information ketween twa parties for a specific purpose” 0 National standards for ele offe transactions 0 The trar § Aealth claims and equivalent encounter information tronic healthcare transactions are designed to improve offiviency and venoss of the healthe ed for electronic ro systom by standardizing the formats u ctiens include ' Enrollment and digenrollment in a health plan 1 Eligibility for a health plan ' Healthcare payment and romitranve advice © Health plan premium payments © Hovlch claim status 8 Refer cortification and authorization ordination of benefits # Any covered entity performing one of these transactions clectronically is required to follow the standards sot for standard use 0 The cade sets include: a HCPCS (Healthcare Commen Procedure Coding System) a CPT Current Procedural Terminology) 8 CDT (Common Dental Terminology) # IGD-10-GM (Prior to October 1, 2015, this B ONDG . An additional standard required in all tran: as KCN—§-CM) Drug Codes) -tions is unique identifiers for providers, health plans, and employers 0 The identifier for providers is the National Provider Mentifior (NPD 0 The identifier for employers is the Employer Identification Number (EIN) ned to employers by the IRS. The Need for Privacy and Security . HIPAA provides federal protections for protected health information (PHD when held by covered entities 0 Hanentity is nota covered entity, itdocsn’ thave to comply with the Privacy Rule or the Security Rule © The Office for Civil Rights (OCR) enforces the HIPAA Privacy Rule, which protects the privacy of individually identifiable information: 0 The HIPAA Security Rule sets national standards for the security of clactronic protected health information 0 The Coufidentialiiy provision of the Palient Safety Rule, which protect identifiable information being uscd to analyze patient safety events and improve pationt safety ¢ The OCR related a documenta callod HIPAA Administrative Simplification 0 Discugses the healthcare provider’ s responsibility surrounding PHI for treatment, payment, and healthcare operations (PPO) 0 Healthcare providers are responsible for developing Notices of Privacy Practives and policies and procedures regarding privacy in their practices How HIPAA Works . Ake provision of HIPAA is the minimum necessary requirement Only the minimum necessary PH] should be shared to satisfy a particular purpose. 0 If information is not required te sat sfy a particular purpose, it must he withheld . Under the Privacy Rule, the minimum necessary standard docsn’ t apply to the follewing: losures to or requests by a healthcare provider for treatment purposes lasures to the individual who is the subject of the information 0 Uses or disclosures made pursuant to an individual’ ¢ authorization 0 Uses or disclosures required for compliance with the HIPAA Administrative Simplification Rules 0 Disclosures to the US Department of Health & Human Services (HHS) when disclosures of information is required under the Privacy Rule for enforcement purposes 0 Uses or disclosures required by other law . Iris the responsibility of overed entity to develop and implament policies bes suited to its circumstances to moot HIPAA requirements 0 Asa policy requirement, only those individuals whose job requires it may have access to PH] 0 Only the minimum PHI required to do the job should be shared 0 If the entire medical recerd is nec ry. the covered entity s polivies and procedures must slate so explicitly and inchile justification stan HIPAA TECH and its Imp: ¢ The Health Information Technology for Economic and Clinical Health Act (HITECH) was enacted as part of the American Recovery and Reinvestment Act of 2009 (ARRA) “to promote the adoption and meaningful use of health information technology 0 Portions of HITECH strengthen HIPAA rules by addressing privacy and security concerns associated with the clectronic transmission of healch information 0 HITECH established four culpability for releasing procacted information — and minimum and maximum ponaltios. 0 HITECH al which any violation not due co willful neglect may be corrected without penalty attogorios of violations — depending on the covercd entity’ s level of » lowers the bar for what constitutes: violation but provides a 30-day window during 0 AITECH allows pationts to request an audit trail showing all disclosures of their health information made through an electrenic record osure or use of his 0 AITECH also requires an individual to be notified if there is an unauthorized dis or her health informaticn © Doctors of aptometry # | Doctors ol osteopathy © Doctors of podiatric medicine © Nurse practitioners © Physician agsistants & Clinival nurse specialists a Nurse anesthetists & Clinival psychologists a Physical therapists & Occupational therapists. & = Qualified speech-language pathelogi © Qualified audiologists 1 Registered dietitians or nutritionists 0 Those MIPS cligible clinicians are automatically excluded from reporting requirements and payment adjustments if: 1 Thoy are in thir first yoar of Madicare. 1 Thoy are Qualifying APM Participants (dofinad lacer) a They do not mector exceed the “lew-volume threshold” 0 The low-volume threshald is alse subject to change por CMS discretion & The low-volume threshold finalized for the 2014 performance year and beyond excludes MIPS eligible clinicians/groups whe (uring the determination period) . Have less than er equal to $80,000 in Part B allowed cl rges for coverad professional services # Provide care to less than or equal to 200 Part B—cnrolled patients # Provide loss than or equal to 200 covered professional services under the Modicaro Physician Fee Schedule (MPES) 0 — Beginning in 2019, MIPS cligible clinicians or groups oxeoad at least one (hut not all three) of these criteria © Those who opt in are held to the same reporting requirements and payment adinstments as everyone else in the program meet or exceed all three criteria) may voluntarily report quality data to C 1 Volunteers do not qualify for +/— adjustments, thoy do receive a performance feedback repert from CMS 1 Clinicians/groups participation in gither MIPS or and Advanced APM Submitter Types # MIPS cligible clin to CMS 0 Asan individual o Asa o AS 0 Asan APMentily Submission Types ans — now referred to as submitter types — may submit data on measures group virtual group © Submitrer types submit data on measures and activitios using CMS—approved submission mechanisms — referred ta as submission types ¢ | There are several ways individual and group reporters can submit MIPS data to CMS 0 Including direct, log in and upload. log in and attest «nd Medicare Part B cl: an opt into the program if they meet or © Asanalternaive le opting in, clinicians who are nal eligible Lo parvicipate in MIPS (hey do not an use this report to assess their performance «nd prepare for fucure ind activities ¢ CMS propeses to remove the CMS Web Interface collaction type and submission type for groups and virtual groups beginning with the 2021 performance poriod 0 Certain restrictions apply & EX: beginning with the 2019 performance year, only small practices (< 15) may submit quality data via Medivare Part B claims, and only groups of 25 or more clinicians may submit data via che CMS Web Interface ¢ The MIPS performance year (when data is collected) is January | through December 21, 0 Participation providers must submit their data to CMS between Jan | and Mar?] follwing the perfarmance year using the appropriate submission typo Collection Types # Collection types are quality measure sets with comparable specifications and data completeness eriteria such as clectreni¢ clin’ quality measures (oCQMs), MIPS clinical quality measures (CQMs), qualified clinical data registry (QCDE) measures, Medicare Part B claim measures, CMS Web Interface measures, the Consumer Assessment of Teallhcare Providers & Systems (CATPS) for MIPS survey measure, and administrative claims measures Sollector types may use a combination of collection types to submit their data (some restrictions) Lollection types are delineated by the four MIPS performance categories o Quality 1 Goal is to assess the value of care to ensure patiants get the right care at the right time 1 MIPS cligible clinicians. groups must submit at loast six quality measures for the 12— month performance period mE measure is worth a maximum of 10 points for a max of 60 achievement points © Note: tho way in which measures aro scored is rather complicated and beyond scope of [his come Promoting Interoperability © Goal: promote Lhe secure exchange of health inforutation and the use of certified electronic health record technelogy (CEART) for coordination of care iT As with the other vategorios, cach measure in the Pl category is now scored based on the MIPS eligible clin a numerator or denominator, ora yes or no submission in’ s performance for that measure, based en the submission of ¢ The scores for cach of the individual measures are added together to calculate a scope of up to 100 possible points § The four objectives and measures are: © obreseribing © Health information exchange . Provider to patient exchange . Public health and clinical data exchange 1 Clinicians are required to report measures from cach of the four abicctives for $0 continuous usion is claimed from this ys, unloss an exe egory . In addition to submitting measures, clinicians must: 0 Submita “yes” tothe Prevention of Information Blocking Attestation © Submita “yes” te the ONC Direct Review of Attestation © Submita “yes” for the Security Risk Analysi an be attested on QPP.CMS.GOV a In 2018, providers had 2 options hased on the provider’ s EHR edition: # Pi measure data . 1, Program Interoperability Program Objective and Measures 1 Measure specifications only include items and services that are related to a spocific condition ction, . EX: intracranial hemorrhage or cerebral infa simple pneumonia w/ hospitalization and ST— clovation myocardial infarction w/ porcutancous coronary intervention © Achievement points for Cost measures are determined by comparing performance toa benchmark created using performance data from the performance period MIPS Final Score . h Performance category ortain amount of weight in the MIPS final score 0 The weights of Quality and cost have changed each year as MACRA requires the cost category to be 30% af lhe MIPS final score by performance year 202: # CMS is implementing thar in requirement in phases Category Yoar 1 Yoar 2 Yoar 3 Yoar 4 Yoar 5 (Final Rule (Final Rule (Final Rule (Final Rule (Proposed CY 2017, 2019 CY 2018, CY 2019, CY 2020, Rule CY payment year) 2020 2021 2022 2021. 2023 payment payment payment payment year) year) year) year) Quality (replaced 60% BOS 45% 45% 40% PORS) Promating 5 Interoperability (previously Advancing Care information, replaced Meaningful Use) Improvement Activities 18% 159% 159% 159% 159% Cost (replaced Value 05 10% 159% 159% 20% based Modifier) ¢ The higher the MIPS final s: 0 If you know the total points earned for each category. you can use AAPC’ s MIPS Score 2. the higher the paymen idjustment Caleulater te calculate your MIPS final Advanced Alternative Payment Models (APM) ¢ An APMisa group of coordinated high-quality vare to Medicare patients, sore ans who have volunaril come Logether in an organized way Lo deliver 0 Advanced APM entities agree to: a Uso of certified EAR technology (must be certified under 2015 criteria) comparable to MIPS § Fither bear mere than nominal risk for financial losses or is a Medical Home Model 1 Base paymont on quality meas expanded tinder CMS Innovation Cemer authorily . Adyanved APMs include 0 Bundled Payments for care Improvement advanced; Comprehensive End Stage Renal Disease Care — two- sided risk; Comprehensive Primary Care Plis, and others . MIPS eligible clinic determination period (snapshot) are not required vo report MIPS data tls through an Advanced APM or the All-Payer and Other Payer option ans who are on the participation list of ene ar more Advanced APMs during a 0 They ma qualify for a 5% incentive if they achieve thresheld levels of payments or pationts: & Snapshot dates are March 31, June 30, and August 31 . Asan added incentive, Qualifying Participants of Advanced APMs willreccive a single conversion payment factor of 0.73% beginning in 2024, whereas all other clinicians will receive 0.28% ¢ To date, cligible clinicians in a MIPS APM are required te participate in MIPS through their APM entity under the APM Scoring Standard 0 In the 2021 PFS with the 2021 performance period proposed rule, CMS proposes to discontinue the APM Scoring standard beginning The Nood for Compliance Rules and Audits # All provider offices and healthcare facilities should have, and actively use.a compliance plan 0 A compliance plan is a written process for coding and submitting accurate ckiims 0 Includes mechanism for detecting and correcting claim errors 0 A Compliance plan may offer several benefits. among them: curate payment of claims © Fewer billing mistakes § Diminished changes of a payer audit § Loss change of violating self-referral and anti~ kickback statutes . Additionally, the increased of provider decumentation that may result from a compliance program, cura may assist in enhancing patient care 0 — Compliance programs show the provider practice is making a good faith effort to submit claims approprialely and sends a signal to employees that compliance is a priority 0 It should also provide a means to report erroneous or frandulent conduct, so that it may be arrected A condition or he Patient Protection and Affordable Care Act. makes compliance plans mandatory participation in federal healthcare programs, 1) However there is not yeat an implementation date for the mandatary compliance © The Office of Inspector Gonoral (OIG) — a government agency tasked “to protect the integrity of HHS programs, as well as the health and welfare of the beneficiaries ef those programs” — offers compliance program guidance to form the ba ¢ of a volmtary compliance program for a provider pr: 0 The OMG Compliance Program Guidance for Individual and Small Group Physic was published in the Federal Register on 10/5/2000 0 This document remains appropriace guidance for compliance in provider offices today # | The seven key componente of an affective compliance plan include 9 — Conducting internal monitoring and auditing through the performance of periodic audits 1 This ongoing evaluation includes not only whether the provider practice’ s standards and procedures are current and accurate, but also whether the complia ¢ program is working © (Kor EX: whethor individuals are properly carrying out their responsibilities and claims are being submitted appropriately) 0 Implementing compliance and practice standards through the development of written standards and procedures a After the internal audit identifies the practice’ s risk areas, the next stepis to 
