Coding & Reimbursement

TINs, the VBPM, and you

By Suzanne L. Corcoran

Most are aware that CMS will be implementing a new value measurement system in a couple of years. In the meantime, we need to understand the systems already in place. One important example: the Value-Based Payment Modifier (VBPM).

Q. What is the VBPM program?

A. The VBPM program evaluates the performance of physicians on the quality and cost of care they provide to their fee-for-service Medicare beneficiaries. The VBPM is applied both to solo practitioners and groups as identified by their taxpayer identification number (TIN). For each TIN subject to the VBPM, CMS uses quality and cost metrics to calculate a value modifier that adjusts the TIN’s physicians’ Medicare physician fee schedule (MPFS) payments — upward, downward or not at all — based on the performance of the TIN.

As with other CMS metrics (such as PQRS), there is a lag. For example, services provided in 2014 affect 2016 Medicare payments. For the 2014 data-reporting period, a large majority of physicians saw no adjustment to their MPFS.¹ Administrators can learn if the VBPM has any impact on their physicians by viewing the confidential Quality and Resource Use Reports (QRURs).

Q. How are Medicare beneficiaries assigned to a TIN?

A. In two steps. Most Medicare beneficiaries are assigned to the TINs of primary care physicians (PCPs). These are defined as family practice, internal medicine, geriatric medicine or general practice physicians. Only if a Medicare beneficiary did not receive primary care services from a PCP is the beneficiary possibly assigned to a specialist, such as an ophthalmologist, and then only to a specialist who provided more primary care services than any other physician or health-care professional in the reporting period. So, relatively few Medicare beneficiaries are assigned to TINs of ophthalmologists.

VBPM applies only if the TIN of the ophthalmologist (or relevant group practice) is assigned applicable Medicare beneficiaries. An applicable Medicare beneficiary is one who receives primary care services from the ophthalmologist (or group) to an extent that exceeds all other TINs who also serve that beneficiary during the reporting period. Primary care services include CPT codes for evaluation and management (E/M) services rendered in-office, nursing facilities, rest homes or the patient’s home.² Inpatient services and emergency room services are excluded from “primary care services,” and eye codes (920xx) are omitted from the defining code set.

Q. Can an ophthalmologist identify these beneficiaries at the time of service?

A. No. It is not feasible or practical to determine if a Medicare beneficiary has been assigned to a TIN, or which TIN, at the time of service.

Q. Does the VBPM calculation include drugs administered by physicians?

A. Yes. All costs incurred within Part A and Part B Medicare are included in the cost-reporting metrics for VBPM. These include Part B Medicare reimbursements for all outpatient procedures and drugs used during these procedures, including drugs administered by intravitreal injection.

The impact of drug costs varies. For the majority of Medicare beneficiaries with one or more chronic diseases, medications represent a negligible part of their health-care costs in the calendar year. In the exceptional case, in which a Medicare beneficiary assigned to an ophthalmic TIN has no other health-care services during the same year, the impact on cost is notable.

Q. Are any Medicare beneficiaries excluded from the VBPM calculation?

A. Yes. Medicare beneficiaries who elect a Medicare Advantage plan or reside outside the United States are excluded from the VBPM calculation. In addition, Medicare beneficiaries who do not receive primary care services are not assigned to a TIN. This might occur if: a) the beneficiary only receives inpatient or emergency care, or b) the beneficiary is not cared for by any physician or other health-care professional. OM

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Suzanne L. Corcoran is vice president of Corcoran Consulting Group. She can be reached at (800) 399-6565 or www.corcoranccg.com.