The sewering ban, one of the more stringent changes outlined in EPA's rule, is the only part of the rule that takes effect at all healthcare facilities nationwide.
A new Environmental Protection Agency (EPA) regulation banning the sewering of hazardous waste pharmaceuticals takes effect Wednesday. Experts say the best way for organizations to ensure compliance may be for them to enact their own policies that prohibit the flushing of any and all drugs into the sewers.
A blanket ban on flushing drugs would also help to ease requirements on front-line staffers who would no longer have to keep track of what they can and can't send down the drain. And it may help organizations stay on the good side of federal regulators, who are touting the outright ban as a best practice to protect water resources.
This compliance deadline marks the first set out in regulations the EPA published in a final rule last February that sets up a new category, Subpart P, under the federal Resource Conservation and Recovery Act (RCRA).
The ban is the only part of the rule that goes into effect at all healthcare facilities across the United States and its territories, without exception. That's because the EPA is declaring the ban under the authority set out by the federal Hazardous and Solid Waste Amendments (HSWA). Other parts of the final rule are under RCRA and must be approved in each state or territory that has its own RCRA-authorized program.
The sewering ban is one of the more stringent changes outlined in the rule. And the EPA only has the authority to ban flushing of those drugs deemed to be hazardous waste, as outlined under RCRA regulation, notes Wade Scheel, director of governmental affairs for Stericycle Environmental Solutions. However, in the preamble to the final rule, the EPA "clearly makes it known" its position on sewering of all drugs, Scheel says.
That preamble states: "We note that although our RCRA statutory authority limits us to apply the prohibition on sewering narrowly to pharmaceuticals that are RCRA hazardous wastes, EPA strongly recommends as a best management practice to not sewer any waste pharmaceutical (i.e., hazardous or non-hazardous) from any source or location."
The EPA even goes on to ask households to do the same.
The concern is that public sewer and water systems were not designed to filter out what has become very complex chemical and biological elements found in many drugs, even if they're not technically considered hazardous waste, Scheel says.
The federal agency backed off on many of its ire-inducing proposals that would have drastically reshaped how it pays for and assesses the accuracy of E/M services.
Editor’s note: This excerpt was taken from an article that orignally appeared on Part B News, a sibling publication to HealthLeaders.
The Centers for Medicare & Medicaid Services hit the brakes on making imminent changes to the oft-used evaluation and management (E/M) code set that's tied to billions of dollars in medical practice revenue.
Streamlined payment rates are off the table for 2019, as are vast documentation revisions, according to the 2,378-page final 2019 Medicare physician fee schedule released Thursday.
That doesn't mean changes aren't coming January 1—or beyond. The federal agency plans to weave a number of smaller updates into the E/M payment and documentation picture in 2019 and will implement a broader array of changes in 2021, including a single-rate payment structure for certain new and established codes.
Following up on a proposed rule that left many in the medical practice profession holding their breaths, however, CMS backed off on many of its ire-inducing proposals that would have drastically reshaped how it pays for and assesses the accuracy of E/M services.
"Commenters largely objected to our proposal to eliminate payment differences for office/outpatient E/M visit levels 2 through 5 based on the level of visit complexity," CMS states in the final rule. Many commenters said they would experience pay cuts and generally let the agency know that the "aggressive" launch date that CMS proposed for January 1, 2019, was far too fast.
Instead, in 2019 and 2020, CMS will maintain separate payments for each distinct E/M code. Practices also will continue to use the current 1995 and 1997 documentation guidelines to guide their way. In a related case of standing-pat, podiatrists will not be singled out with a separate E/M reporting structure. In other words, it’s largely business as usual.
However, take note of some meaningful changes that CMS will adopt starting January 1:
For E/M visits, providers will not be required to re-enter information about the patient’s chief complaint and history that a staff member has already entered. Instead, the provider can indicate in the medical record that the information has been "reviewed and verified," CMS says.
For established office visits, providers can focus their documentation on changes since the last visit and "need not re-record the defined list of required elements if there is evidence" that the provider has already done so, an accompanying CMS fact sheet states.
For home visits, providers will no longer be required to prove explicit medical necessity when reporting a certain range of codes.
The agency believes these measures will provide "immediate burden reduction," something it has emphasized in recent rulemaking periods.
What it means for providers
For medical practices, changes to E/M services can have a big effect on financial health. E/M encounter codes for established patients make up a huge source of revenue for physician practices. In 2017, medical groups gained more than $13 billion on claims for codes 99211-99215. About 80% of that revenue is tied to just two codes—99213 and 99214—which account for most patient visits.
Many commenters called on CMS to take a more cautious approach, and CMS ultimately agreed.
"A delayed implementation date for our documentation proposals would also allow the AMA time to develop changes to the CPT coding definitions and guidance prior to our implementation, such as changes to MDM [medical decision-making] or code definitions that we could then consider for adoption," CMS states. "It would also allow other payers time to react and potentially adjust their policies."
Despite a two-year slowdown, CMS anticipates going full-throttle into 2021 with a series of major revisions to E/M coding, payments and documentation requirements.
Quality Payment Program changes
More types of providers will have to participate in the Merit-based Incentive Payment System (MIPS) of the Quality Payment Program (QPP). In 2019, physical therapists, occupational therapists, clinical psychologists, speech-language pathologists, audiologists, registered dietitians and nutrition professionals are eligible for the program. CMS had proposed including clinical social workers and nurse-midwives, but those types didn’t make the cut.
Small practices get some breaks in the 2019 QPP. Practices with 15 eligible clinicians (ECs) or fewer get a six-point bonus automatically in the Quality category. In addition, those practices still will be able to report Quality measures via claims. Starting in 2020 while larger practices get zero points for measures that do not meet data completeness—that is, that do not represent the required 60% of their patients for the period—measures submitted by small practices will continue to receive three points even if they don’t hit that target.
Also, small practices may be excused from the program if they can’t meet at least one of three criteria—$90,000 or less in Part B allowed charges for covered professional services; 200 or fewer Part B-enrolled beneficiaries; or 200 or fewer covered professional services under the fee schedule. But those who meet at least one of these criteria may opt in if they want.
As proposed for MIPS, 10 measures—four process-related, four patient-reported outcome and two patient-reported process measures—will be added to the Quality category; 26 measures were removed, as opposed to the 34 proposed to be deleted.
For 2019, participants must choose from nine Promoting Interoperability measures, complete six and also finish two bonus measures. Six new Improvement Activities are added, including “Comprehensive Eye Exams” and “Financial Navigation Program.”
Cost performance will be measured on total per capita cost versus Medicare spending per beneficiary as derived from Medicare claims. Participants also will have their Cost performance counted against eight new episode-based measures if they are attributable in any of 10 or more procedural episodes, such as Elective Outpatient Percutaneous Coronary Intervention (PCI), or 20 or more acute inpatient medical condition episodes, such as Simple Pneumonia with Hospitalization.
Quality is 45% of your score in 2019, cost 15%, Promoting Interoperability (the former Advancing Care Information) 25% and Improvement Activities 15%. The performance threshold to fulfill MIPS is 30 points; the additional performance threshold to be eligible for a bonus is 75 points.
The Advanced Alternative Payment Model (APM) alternative to MIPS gets a little tougher in some ways – for example, at least 75% of clinicians in the APMs must use up-to-date certified electronic health records technology (CEHRT), up from 50% this year. The revenue-based nominal amount for entry into the program will remain at 8% through 2024.
Editor’s note: This excerpt was taken from an article that orignally appeared on Part B News. Get every last detail on E/M changes and more from the final 2019 Medicare physician fee schedule with the one-hour webinar 2019 E/M Forecast: Prepare Your Practice for Fee-Schedule Changes on November 28. Register atwww.codingbooks.com/ympda112818.
The facility allegedly failed to respond adequately to a number of incidents that resulted in serious injury to workers during the past two years.
Be aware that OSHA is continuing to cite healthcare organizations for not protecting their staff from workplace violence.
In the latest announced penalty, an acute care inpatient behavioral health facility in Bradenton, Florida, is facing more than $71,000 in fines for “failing to institute controls to prevent patients from verbal and physical threats of assault, including punches, kicks, and bites; and from using objects as weapons,” according to information released by the U.S. Department of Labor.
OSHA cited Premier Behavioral Health Solutions of Florida Inc. and UHS of Delaware Inc., which operates Suncoast Behavioral Health Center in Bradenton, after investigating a complaint that employees were “not adequately protected from violent mental health patients.” The citation, announced May 2, follows the OSHA citation of another UHS subsidiary in 2016 “for a deficient workplace violence program.”
“This citation reflects a failure to effectively address numerous incidents over the past two years resulting in serious injuries to employees of the facility,” said Les Grove, OSHA Tampa Area Office Director,in a news release.
Regulators and accrediting organizations are cracking down on failures to protect workers from violence. The Joint Commission issued a Sentinel Event Alert in April, and OSHA is considering proposing a new standard to deal just with workplace violence, which currently is cited under the General Duty clause requiring employers to protect workers from hazards “that are causing or are likely to cause death or serious harm.”
The OSHA citation report offered up a list of problems and potential solutions for Premier Behavioral Health Solutions and UHS to consider. Those solutions included:
Evaluating the configuration of the nurses’ workstations to keep patients from jumping over desks or otherwise gaining access to personnel as well as weapons such as staplers, phones, cords, pens, and computers
Developing a “disruptive behavior response team” and provide that team with “clear written procedures for how employees should respond to clients making threats, showing aggression, and assaults
Evaluating intake procedures to better identify incoming patients with potential for violence
Ensuring security cameras are continuously monitored
Providing panic alarms
Discouraging employees from wearing necklaces or lanyards that can be used for strangulation, and encourage staffers to secure “loose hair so that it is not accessible to patients, to minimize the risk of neck strains and hair pull injuries”
Regularly training staff in methods to protect themselves when patients become violent
Conducting effective investigations and root cause analyses into violent events
Establishing a comprehensive medical and psychological counseling and debriefing for employees experiencing or witnessing violent assaults or incidents
Premier Behavioral and UHS have 15 business days from when they were notified of the citations and penalties to pay the fines, request an informal conference with OSHA’s area director, or contest the findings before the independent Occupational Safety and Health Review Commission.
This OSHA citation follows a similar case last year in which a psychiatric treatment center in Massachusetts faced more than $207,000 in proposed penalties after OSHA accused the facility of failing to adequately protect employees from workplace violence, despite having promised specifically to do so. That center said it was contesting OSHA’s allegations.
Small practices could add points to their total performance scores in the merit-based incentive payment system and may qualify for an exemption from EHR requirements.
More small practices may qualify for exclusions from the Quality Payment Program (QPP), claim hardship exceptions from electronic health record (EHR) requirements, and earn automatic bonus points if the proposed QPP rule released June 20 is finalized.
The Centers for Medicare & Medicad Services has proposed increasing two low-volume thresholds that would grant additional exclusions in 2018:
Practices that bill less than $90,000 in Part B charges.
Practices that see fewer than 200 Medicare patients.
These practices would be exempt from QPP requirements in 2018. Those figures are up from $30,000 in Part B charges and 100 Medicare patients in 2017.
Small practices, defined as having 15 or fewer eligible clinicians, also could add five points to their total performance scores in the merit-based incentive payment system (MIPS) "as long as the eligible clinician or group submits data on at least one performance category in the applicable performance period."
That would get them closer to the proposed 15-point performance threshold.
Eligible providers that don't fit within those categories would have to meet these QPP requirements to avoid a 5% cut, or potentially earn a 5% bonus in 2020, according to the proposed rule.
Quality Reporting / No Changes
Eligible providers would need to report six quality measures for at least 50% of encounters that meets a measure's specifications.
Improvement Activities (IAs) /No Changes
Most providers would need to report four activities. Providers who are in rural areas, geographic health professional shortage areas or meet the definition of non-patient facing must report two activities to receive a full score. CMS also will add more improvement activities that show the use of certified electronic health record technology (CEHRT).
Advancing care information (ACI) / Some Changes
Providers would be able to use the 2014 or 2015 edition CEHRT next year to participate in ACI. That's a reversal from the agency's stated plan in last year's final rule. Providers using 2015 CEHRT would have to report 15 measures while those using 2014 CEHRT would have to report 11. Small practices would be able to take advantage of a hardship exemption that would mean they would not be scored on their ACI performance.
CMS would shift the score for the category to the quality performance category. CMS intends to add exclusions for the e-prescribing and health information exchange measures. It plans to allow clinicians "to not report on the immunization registry reporting measure and potentially earn 5% each for reporting any of the public health and clinical data registry reporting measures as part of the performance score, up to 10%."
CMS Won't Count Resource Use in 2018 Scores
The resource use, aka cost, category that was not scored in 2017 would continue to be unscored in 2018. For the initial MIPS year, the cost category did not count toward the final MIPS score, but CMS planned to make the cost category worth 10% of scoring in 2018.
However, this rule proposes to keep it at 0% for the 2018 performance year/2020 payment year "to improve clinician understanding of the measures and continue development of episode-based measures that would be used in this performance category."
To that end, CMS would develop new episode-based measures "with significant clinician input," the rule says. The quality category is staying at 60% of the score rather than moving down to 50%, as was originally proposed.
Apportionments Would Not Change
If the proposed rule is finalized, the apportionments in 2018 would remain at current levels: 60% for quality, 25% for advancing care information, and 15% for clinical practice improvement activities:
Reporting periods for various MIPS components could vary. Under the proposed rule, providers would need to report quality measures for a full year, up from 90 days in 2017. However, the required performance period for ACI and IAs would remain at 90 days, according to the proposed rule.
Virtual groups are on the horizon for 2018. Be prepared to get virtual in year two of the MIPS program, when CMS is proposing to open up virtual-group reporting. That means small group practices – either solo providers or those with 10 or fewer clinicians – could band together and report the full MIPS slate as a single unit.
Virtual groups would need to surpass the proposed low-volume thresholds in order to be eligible for the joint reporting option. CMS notes that interested providers would be required to elect the virtual-group reporting option before the calendar turns to 2018.
Risk under advanced alternative payment models (APMs) are extended. Providers would find the same 8% required potential risk for APMs through 2020, according to the proposed rule.
The risk amount, which is based on total Medicare revenue, was already locked in for 2018, but now providers will find two additional years on the docket at the current rate.
The final codes include 322 more changes than what was proposed by CMS in April's hospital IPPS rule.
Starting Oct. 1, it will be possible to select a specific ICD-10-CM code when a patient is in remission from abuse of each of a variety of substances, including alcohol, opioids, cannabis and nicotine.
Those nine new codes are among 360 new, 142 deleted, and 226 revised diagnosis codes in the final 2018 update posted by the Centers for Medicare & Medicaid Services to its website on June 13.
The final 2018 ICD-10-CM codes include 322 more change hospital IPPS rule in April.
Explanatory information included with the substance abuse remission codes will classify the severity of the use as mild, moderate, or severe to better coordinate ICD-10-CM coding with the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
Further changes in the final code set include:
Myocardial infarction (MI) codes added. New codes for myocardial infarction type 2 (I21.A1) and other myocardial infarction type (I21.A9) mean you will need to take into consideration the type of MI the patient is having. A type 2 MI describes a myocardial infarction due to demand ischemia. In addition, notes added under ST-elevation MI codes (I21.0-I21.4) clarify that the condition is a type 1 MI.
Heart failure gets new codes. The code set has new codes for various types of right heart failure, including acute (I50.811), chronic (I50.812), acute on chronic (I50.813) and unspecified (I50.810). There are also new codes for right heart failure due to left heart failure (I50.814), biventricular heart failure (I50.82), high output heart failure (I50.83) and end-stage heart failure (I50.84) for patients with an advanced form of the disease who no longer respond to medication.
Antenatal screening codes expand reporting options. Medical practices will be able to report specific screening tests administered to pregnant patients, such as fetal growth retardation and chromosomal abnormalities with 17 new Z codes.
The final code set includes more than 100 deletions that were not in the proposed code set, including a reversal on new codes. Here are the highlights of those changes:
Three anorectal abscess codes for horseshoe, ischiorectal, and supralevator abscesses were issued in the proposed code set but were not included with the final codes.
The head injury section of Chapter 19 will lose 68 subsequent encounter and sequela codes.
Thirty-six thumb subluxation and dislocation codes have been deleted. The codes represent initial and subsequent encounters, as well as sequela.