By Peter M. Diemer, JD
Clayton & Diemer LLC

I have received several questions regarding the new Medicaid ICD-10 requirement for prescriptions in response to my recent healthcare law update.

This requirement is separate from the Alaska Prescription Drug Monitoring Program (AKPDMP) registry requirements.  The AKPDMP applies to all providers with DEC registration and is not Medicaid or Medicare specific.  The AKPDMP does contain several exemptions from the registry requirement.  For example, AS 17.30.200(a) and (b) exempt controlled substances administered to a patient at a health care facility. The AKPDMP also exempts emergency department physicians from reviewing the database prior to prescribing or dispensing inpatient or in emergency department. AS 17.30.200(k)(4)(A)(i) and (iii).

I have not identified any exemptions from the ICD‐10 diagnosis code requirement for Medicaid services.  Earlier this summer I spoke with Erin Narus, the Pharmacy Program Manager, on this issue.  She confirmed that no exemptions exist to the Medicaid requirement.  She also stated that the State is launching a “soft” roll out of the requirement.  Despite this, I emphasize that it remains a current requirement for Medicaid reimbursement.  Narus also invited feedback from providers and stakeholders to assist in refining the requirement and indicated that some exemptions may be considered.

The next Drug Utilization Review Committee meeting is Friday, September 15, 2017 at 1:00 p.m. in the Frontier Building, 3601 “C” Street; Room 880, Anchorage, Alaska. If  you would like to join via teleconference, call 1.800.315.6338, use access code 24251#

The ICD-10 requirement is on the agenda.

Certain provider groups, such as emergency department physicians and chronic pain management physicians, may interface with this requirement more often and should monitor developments.

And in other information…

Aetna to Terminate Pass Through Lab Billing September 1st.
Aetna announced that effective September 1st  it will deny pass-through billing for most laboratory charges from a facility or a non-facility provider. The provider that performs the test must bill for these services.

This change in Aetna policy may have a substantial impact on practices that do not have a physician lab.  Such practices might consider establishing a physician lab or consider a possible block lease of an existing qualified lab.  Under certain circumstances a physician office can block lease a lab during which time it operates as the lessee’s physician lab.  For CMS participating providers block leasing can be complicated but possible.

No Further Action on 80th Percentile Rule
In January the Alaska Division of Insurance held scoping hearings on the so-called 80th percentile rule, 3 AAC 26.110.   The insurers and employee benefit management companies uniformly came out against the rule while providers were mostly in support of maintaining the current rule.  We expected that the Division of Insurance would take no action until Congress had opportunity to make changes to the ACA.  Now that Congress has not acted on the ACA, the Division of insurance may resurrect this matter.  We encourage providers to be vigilant on this issue.

Alaska Prescription Drug Monitoring Program
The Alaska PDMP underwent some changes.  Providers who are licensed by DEA are now required to register with PDMP. Unless an exception applies, prescribing providers are required to check the PDMP database before prescribing.  Providers may delegate database review to only persons who hold a license issued pursuant to Title 8 of the Alaska Statutes (i.e. a nurse, etc.).  Note that Certified Medical Assistants (CMA) are not licensed in Alaska and thus, this task may not be delegated to them.

CMS Merit-based Incentive Payment System (MIPS) 2017 Participation Deadline October 2
For those practices which accept Medicare, time is running out to consider whether there is any advantage to participation in the Merit-based Incentive Payment System (MIPS) introduced through the October 2016 Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

On October 14, 2016, CMS released the final rule for the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). MACRA repeals the Medicare Part B Sustainable Growth Rate (SGR) reimbursement formula and replaces it with a new value-based reimbursement system called theQuality Payment Program (QPP). The QPP consists of two compliance tracks:

Follow the embedded links for more information directly from CMS.

Most practices will not qualify for Advanced APMs, leaving MIPS as the only practical compliance option.

In sum, MIPS applies to all CMS providers who bill $30,000 or more annually to CMS or treat more than 100 CMS qualified beneficiaries each year.  If your practice falls below the threshold then reimbursements will not be penalized for non-participation.  There are some other notable exceptions such as hospitals and facilities.  Further, a new CMS enrolled provider is not required to participate during the first year of enrollment.

Otherwise, 2017 is the year in which a provider must initiate participation to avoid a future 4% reduction of reimbursements.  A minimum level of participation is required to avoid this reduction.  Further participation is required to achieve an enhancement.

MIPS is comprised of four areas: (1) Quality Measures, (2) Improvement Activities, (3) Advancing Care Information Activity, and (4) Cost.  Initially Cost will not be weighted.

The minimum level of participation in 2017 to avoid a 2019 reduction is to collect and report one Quality Measure or Improvement Activity for one point in 2017.

Positive adjustment may be achieved through a full 90-day participation period in 2017.

This means that a practice must start its collection no later than October 2, 2017, to meet the 90-day requirement for 2017.

Navigation of MIPS is far too complex for this e-mail, but the above links are a good start for a practice to learn more about the four components of MIPS.

State of Reform Conference October 3
The annual State of Reform Conference is scheduled for October 3rd in Anchorage.

Medicaid ICD-10 Requirement