How to Meet MACRA Quality Metrics for COPD Treatment

by | Published on Dec 19, 2017 | Medical Billing

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MACRA, the Medicare Access & CHIP Reauthorization Act and its related payment system reward value of care and is impacting the revenue of hospitals, clinics, physicians’ practices. Reporting for cost and quality categories will include the entire calendar year and continue in 2019, affecting reimbursement in 2021. Outsourcing medical billing and coding is helping many providers meet MACRA reporting requirements. However, complex patients such as Chronic Obstructive Pulmonary Disease (COPD) patients could severely impact quality metrics reporting. In 2018, the Centers for Medicare and Medicaid Services (CMS) will award five bonus points in the Merit Based Incentive Payments System (MIPS) program for treatment of such patients. Physicians will be penalized for costs that exceed anticipated amounts. A recent Medical Economics report points out that positive COPD outcomes will not only benefit patients but also help physicians drive more money to their bottom line.

COPD causes breathing-related problems and blockage of airflow in the body. Symptoms include shortness of breath, coughing, difficulty exercising and history of asthma. COPD is the third-leading cause of death in the United States, but reports say that COPD research funding is low and patients’ access to care is poor compared to other chronic diseases. A 2016 report from researchers at the University of Michigan reported that:

  • COPD affects more individuals with low socio-economic status, and patient access to education, medications and non-medication interventions needs to improve
  • Medical providers, particularly primary care providers lack sufficient training around the disease
  • Out-of-pocket costs for patients, especially those affected by multiple chronic diseases, are a large burden, leading to increased overall health care costs and reduced adherence
  • COPD research funding is low compared to other diseases with high mortality rates and the pharmaceutical industry will need to focus on cost-effectiveness for health care payers and patients.
  • Data for COPD-specific care (such as oxygen therapy) in the clinical setting is limited as also insurance coverage
  • There is need for greater coordination of care, but this remains a challenge. Linking reimbursement to provider performance can help improve care coordination.
  • Quality measures for COPD need to be developed to promote evidence-based, high-quality care.

Adherence to the following COPD treatment best practices can help physicians meet their MACRA quality metrics and increase revenue:

    • Educate patients: Cost control begins with patient education. Medical Economics cites an expert as saying that educating patients and helping them understand how their life choices will affect their chronic conditions is crucial to keep them healthy. Primary care providers (PCPs) play an important role in educating patients as they see patients more frequently. Patient education affects the following four COPD-related quality measures under MIPS:
      • COPD: Prescribing long-acting inhaled bronchodilator therapy
      • COPD: Performing spirometry evaluation
      • Preventive care and screening: Tobacco use-screening and cessation intervention
      • Tobacco use and help with quitting among adolescents

      To control costs of care, PCPs need to understand each patient’s unique challenges. Some patients tend to downplay their symptoms and end up in hospital due tolack of appropriate intervention. Understanding each COPD patient’s specific challenges will allow the physician to develop a customized treatment plan. Patient education has many components:

      • COPD device use: Physicians should consider the patient’s ability to operate a pump inhaler versus a breath-activated inhaler. They can educate patients about COPD triggers and the correct technique of using an inhaler and nebulizer. They should explain the difference between long-acting broncodialaters and rescue inhalers. While broncodialaters can control COPD symptoms and underlying inflammation, rescue inhalers are short-acting devices that can quickly address trigger-induced bronchospasm.
      • Environmental factors: Physicians should tell patients to monitor outdoor air quality and pay attention to allergy counts. They should be advised to stay indoors when allergy counts are high and also make sure the environment they are in is free of dust and mold.
      • How to act in the event of an exacerbation: PCPS need to make sure patients know what to do when they experience signs of an acute copd exacerbation

      Besides giving clear patient instructions, physicians should record the steps in a customized action plan.


  • Understand COPD admission trends: Transitional care management (TCM) can improve health-related quality of life in COPD patients who have recently suffered an exacerbation. TCM helps patients return to community life, prevents readmission, and allows physicians to receive reimbursement for the time spent to identify barriers to treatment. When billing TCM, physicians must meet with patients inside 7 or 14 days of discharge, based on the complexity of the patient’s medical condition. This will provide the physician the opportunity to identify the reason for the admission and the challenges that prevent patient from adhering to the treatment. They should also follow-up with patients who cancel post-discharge appointments.
  • Monitor COPD patients: Physicians must be able to monitor patients with COPD who seek emergency care or urgent care. They should see whether this occurred because patients did not have enough education. Monitoring patients will also allow physicians to understand if they need a change in medication or whether they have comorbidities that need to be addressed. Addressing these factors is crucial to help patients stay healthy and also reduce costs that could ultimately affect physicians’ payments. Physicians’ practices should also work with hospital physicians to treat patients with COPD exacerbation. Internists can provide critical information on the patient’s symptoms, habits and unique challenges

Reducing the frequency and severity of COPD exacerbations reduces the burden on the patient and also on hospitals, thereby reducing the burden of the condition on the health care system. These proactive measures can help patients stay healthy and out of hospital, thereby improving physicians’ quality scores and revenue. Partnering with a reliable medical billing company can ensure accurate claim submission and appropriate reimbursement.

Natalie Tornese

Holding a CPC certification from the American Academy of Professional Coders (AAPC), Natalie is a seasoned professional actively managing medical billing, medical coding, verification, and authorization services at OSI.

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