2019 Payment Adjustment Reminders

Mandatory Payment Reduction – Sequestration
Medicare Fee-For-Service (FFS) claims with dates-of-service or dates-of-discharge on or after April 1, 2013, will continue to incur a 2 percent reduction in Medicare payment until further notice. The claims payment adjustment will continue to be applied to all claims after determining coinsurance, any applicable deductible, adding any positive Merit-based Incentive Payment (MIPS) adjustments and any applicable Medicare Secondary Payment adjustments. Though beneficiary payments for deductibles and coinsurance are not subject to the 2 percent payment reduction, Medicare’s payment to beneficiaries for unassigned claims is subject to the 2 percent reduction.

This reduction appears on your remittance advice (RA) with CO-243 and an associated dollar amount.
*Note: When the total allowed amount for an individual service is applied to the patient’s deductible the Sequestration reduction is not applied to that detail line.

Merit-based Incentive Payment System (MIPS) Payment Adjustments

  • If you participated in Year 1 (2017 performance period of the Merit-based Incentive Payment System (MIPS), you will receive a payment adjustment in 2019. Your payment adjustment is determined by the data you submitted on quality measures and activities for performance during 2017. You can review these details by accessing your performance feedback, which you can view by logging in here: https://qpp.cms.gov/.

MIPS positive payment adjustments appear on your RA with CO-144 and Reason and Remarks Code N807 along with an associated dollar amount. Negative amounts listed on an RA are processed as a positive amount paid.

  • If you were an eligible provider in 2017 and did not send in any 2017 data, you will receive a negative 4 percent payment adjustment in 2019.

MIPS negative payment adjustments appear on your RA with CO-237 along with an associated dollar amount. The associated dollar amount represents a reduction in payment.

MIPS technical assistance and support is available to help you navigate the MIPS program. Visit the QPP website https://qpp.cms.gov/ or call 866-288-8292 weekdays from 8 a.m. to 8 a.m. Eastern Time.

Calculating a MIPS Positive Adjustment with Sequestration Reduction
Example:

Fee Schedule Amount:
1927.07
Applied to Deductible:
-40.50
Sub-Total:
1886.57 (1927.07 - 40.50)
20% Co-Insurance:
-377.31 (1886.57 x 20%)
Sub-Total:
1509.26 (1886.57 - 377.31)
MIPS (indiv. prov. %):
-28.37 (1509.26 x 1.88%) (amount appears on RA with CO-144 and CARC N807 and a negative sign)
Sub-Total:
1537.63 (1509.26 + 28.37)
2% Legislative:
30.75 (1537.63 x 2%) (amount appears on RA with CO-253)
Amt Paid:
1506.88 (1537.63 – 30.75)

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