Pay attention to Remittance Advice on 2019 claims related to QPP/MIPS payment adjustments

In 2019, some practices earn bonuses or received penalties based their 2017 MIPS activity – others are ‘neutral’.  When you file claims for services with dates of service after January 1, 2019, and your remittance advice comes back on those claims, it is important to properly record the MIPS adjustment in your practice management system.  CMS has noted that patient copays and deductibles are NOT affected in any way by your QPP/MIPS bonus or penalty, so don’t add/subtract your adjustment amount to what the CMS Remittance Advice states the patient owes you.  In an official QPP Fact Sheet on this subject, CMS notes: “The payment adjustment is applied to the Medicare paid amount, so it does not impact the portion of the payment that a beneficiary is responsible to pay.” We feel it is best to do this with an internal charge in your system so you do not inadvertently change the patient-responsibility amount.

Remember that how you scored in QPP/MIPS in 2017 has a possible payment effect after skipping a year.  (So your 2017 MIPS result has no effect until 2019, the 2018 activity affects 2020, and so on …).  Don’t be confused by the terminology – CMS does not refer to them as “bonuses or penalties” – they are “positive” or “negative” payment adjustments, respectively.  If you “passed” (no bonus or penalty), it is known as a “neutral” payment adjustment.

You should see new Remittance Advice (RA) codes for MIPS for those claims with dates of service after 1/01/19.  CMS published a separate Fact Sheet on this.  You can link to that here.  There are 3 code types CMS uses to communicate this information:

  • Claim Adjustment Reason Codes (CARCs)
  • Remittance Advice Remark Codes (RARCs)
  • Group Code

If you are getting a positive adjustment, you would see the following line item and a corresponding amount: CARC 144 (“Incentive adjustment …”), RARC N807 (“Payment adjustment based on Merit-based Payment System (MIPS)”, and “CO” for the Group code.  Those getting negative adjustments would instead see: CARC 237 (“Legislated/Regulatory Penalty …”), as well as the N807 and CO codes as above.

Each professional service (exams, diagnostic tests, surgeries) in 2019 is adjusted based on your 2017 QPP/MIPS performance.  Part B drug payments are not affected in any way.

We are happy to assist providers and groups in any way with other topics including MIPS in general, 2018 MIPS attestations, as well as proper code selection, chart reviews, payer action questions – please contact us.  We can also provide training on these or other subjects.  You can reach us via the link to our main webpage or at the phone number below.  You can also download our “App”, Corcoran 24/7, which can be separately accessed via one of the links below. (800) 399-6565

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