Value Based Modifier (VM)
Value Based Modifier (VM) Quick FAQs
The Value Based Modifier (VM) was created by Section 3007 of the Affordable Care Act (ACA) (P.L. 111-148) that mandated CMS begin applying a value modifier under the Medicare Physician Fee Schedule (MPFS). Implementation of the VM began on January 1, 2015, and cost and quality data are required to be included in calculating payments to eligible professionals (EPs). The VM is a value-based payment adjustment (i.e., upward, neutral, or downward payment adjustment) and the application of the VM is dependent on successful reporting of PQRS program quality measures by the group practice.
CMS Disclaimer “Please note, although CMS has attempted to align or adopt similar reporting requirements across programs, EPs should look to the respective quality program to ensure they satisfy the PQRS, EHR Incentive Program, Value-Based Payment Modifier (VM), etc. requirements for each of these programs.”
What is the Value Based Modifier?
Does the VM currently apply to a CRNA that works as an individual practitioner (i.e., not in a group)?
How is payment determined for the VM?
How is the VM performance period and calendar year related to the PQRS program?
How is the VM connected to the Physician Quality Reporting (PQRS) Program?
Who are the eligible professionals under the VM Program?
The following are considered eligible professionals for the purpose of determining group practice size and the application of the VM.
- Practitioners: Certified Registered Nurse Anesthetists, Anesthesiologist Assistants, Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists
- Medicare physicians: Doctors of Medicine, Osteopathy, Podiatric Medicine, Optometry, Oral Surgery, Dental Medicine, or Chiropractic Medicine.
How does participation in the PQRS Program affect my VM payment adjustment?
The VM program officially applies to CRNAs based on the 2016 VM performance period (PQRS 2016 reporting period) and the VM 2018 payment adjustment. Participation in the PQRS Program will be the basis for whether Medicare will apply a VM payment adjustment to a PFS payment. Therefore, a CRNA will incur an automatic VM payment adjustment by simply choosing not to participate in the PQRS program. Satisfactorily reporting PQRS measures allows a CRNA to avoid the -2% PQRS 2018 payment adjustment. For the VM program alone, negative payment adjustments of -4 % in 2018 will be applied to eligible EPs who don’t satisfactorily meet the PQRS program requirements or are considered low quality/high cost providers, therefore, CRNA may incur a penalty of up to 6% when payment adjustments from the VM and PQRS quality programs are combined.
Note: CMS finalized a hold harmless policy under the Quality Tiering portion of the VM program for CRNAs who are solo practitioners or who are in group practices (as identified by the group TIN) that consist only of non-physician EPs such as CRNAs. The hold harmless policy, however, does not apply to CRNAs who work in group practices with physicians. For specifics please see the 2016 Physician Fee Schedule Final Rule. The hold harmless policy only applies to those CRNAs you satisfactorily meet the PQRS program requirements.
When did the VM take effect and to whom does it apply?
|VM payment adjustment in year||VM performance period=PQRS reporting year||Required number of EPs per group||Affected providers|
|2017||2015||Solo physicians and group practices with 2 to 9 EPs||Physicians|
|2018||2016||All||All CRNAs, PAs, NPs, CNSs and physicians|
Final Rule 2015:
It is of great significance to CRNAs that the Physician Fee Schedule 2016 Final Rule finalized the application of the 2018 VM payment adjustment to all CRNAs, PAs, NPs, and CNSs based on their 2016 performance period (PQRS 2016 reporting period). Consequently, it is imperative that CRNAs, billers, and vendors become comfortable with reporting PQRS quality measures so they are prepared to avoid the 2018 VM payment adjustment based on their 2016 performance period (PQRS 2016 reporting period).
As a CRNA, once I satisfactorily report or participate in PQRS am I subject to the 2018 VM quality tiering for the 2016 performance period (PQRS 2016 reporting year)?
What is Quality Tiering and the hold harmless policy?
The hold harmless policy was implemented by the 2016 Physician Fee Schedule Final Rule that exempts CRNAs and other APRN EP solo practitioners and those working in group practices that are composed only of non-physicians (as identified by their TIN) from the VM’s negative payment adjustment for the 2016 performance period (2016 PQRS reporting period), 2018 payment adjustment period if they successfully report or participate in reporting PQRS quality measures. Unfortunately, the hold harmless policy does not extend to all CRNAs and APRNs that work in group practices which include physicians (i.e. mixed interdisciplinary groups). For a detailed explanation of the hold harmless policy see the 2016 Physician Fee Schedule Final Rule.
Quality tiering for 2018 VM Payment Adjustments (2016 Performance Period) [Download Table]
How is Quality Tiering used to calculate the VM payment adjustment?
To learn more about how the VM payment adjustments are calculated please review Sections V-VIII of CMS’ summary of the VM policy.
What is the risk of seeing a negative VM payment adjustment for anesthesia after participating in PQRS?
What are Quality and Resource Use Reports (QRURs) and how are they related to the Value Modifier (VM)?
The Medicare Fee-for-Service (FFS) Physician Feedback Program provides comparative performance information to providers and medical practice groups beneficiaries. The Program (which is specific to FFS Medicare—not Medicare Advantage) contains two primary components:
- Quality and Resource Use Reports (QRURs) - confidential feedback reports
- Development and implementation of the Value-Based Payment Modifier (VM)
The VM Program provides for differential payment under the Medicare Physician Fee Schedule (PFS) based on the quality of care furnished compared to the cost of care during a performance period. As part of the VM Program, CMS decided to provide participating providers with confidential feedback reports known as QRURs.
CMS disseminates Mid-Year QRURs (e.g., 6 month interim reports) in the spring, for informational purposes only, to solo practitioners and group practices nationwide who billed for Medicare-covered services under a single TIN over the Mid-Year QRUR performance period (July 1- June 30). In the fall, CMS disseminates Annual QRURs to solo practitioners and groups of practitioners (including physicians and non-physician eligible professionals that participated in the Medicare Shared Savings Program, Comprehensive Primary Care Initiative, or, the Pioneer Accountable Care Organization Model). The Annual QRUR serves as final summary report of a TIN's quality and cost performance and also reports the VM that was calculated from the TIN's performance two years prior. For detailed information about the value modifier and QRURs visit the Medicare FFS Physician Feedback Program/Value-Based Payment Modifier.
What information is contained in a Quality and Resource Use Report (QRUR)?
The 2016 Annual Quality and Resource Use Reports were released in September 2017. The QRURs are confidential feedback reports that are available to all solo practitioners and group practices that bill Medicare Part B (Physician Fee Schedule (PFS)) based on one Taxpayer Identification Number (TIN). The reports show eligible professionals (EPs) (based on their TIN) how they performed on quality and cost measures relative to national benchmarks under the Value Modifier. The QRURs also indicate whether the EPs are subject to a positive, neutral or negative payment adjustment in 2018 for services rendered under the PFS.
Groups and solo practitioners who believe their Value Modifier calculations were incorrectly assessed may request for an Informal Review. The QRUR Informal Review Period is from September 18, 2017 until December 1, 2017. Detailed information on the 2016 QRUR and 2018 Value Modifier is on CMS.gov. For questions about the 2016 QRUR and 2018 Value Modifier and how to request for an Informal Review, contact the Physician Value Help Desk 1-888-734-6433 (select option 3) or email firstname.lastname@example.org
How will the Value Modifier program be affected by the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015?
Who should I contact for VM or PQRS questions?
Phone: 1-888-734-6433, press option 3.
For questions regarding the PQRS Program please contact the QualityNet Help Desk. The desk is available Monday - Friday; 7am -7pm CST.
Phone: 1-866-288-8912 TTY: 1-877-715-6222