by Mary Dimmock, Susan Levine, MD, and Terri L. Wilder, MSW
Myalgic encephalomyelitis (ME), also known as chronic fatigue syndrome (CFS) or ME/CFS remains an elusive diagnosis to most physicians. There are no simple diagnostic tests or biomarkers, and there are no FDA approved treatments specific to this disease. Clinical guidance has often recommended cognitive behavioral (CBT) and graded exercise therapy (GET), but these therapies are inappropriate and potentially harmful for patients with ME/CFS. In 2015, the Institute of Medicine (IOM, now called the National Academy of Medicine) issued new clinical diagnostic criteria for ME/CFS and summarized the growing evidence of biological impairment. Since then, the National Institutes of Health (NIH) has funded three Centers of Excellence to study ME/CFS, a pediatric ME/CFS primer has been published, and the Centers for Disease Control and Prevention (CDC) has updated its website.
Demographics and Presentation
ME/CFS is believed to affect approximately one million Americans, but actual disease prevalence could be higher. The IOM reported an estimated prevalence of 1 to 2.5 Million Americans, which amounts to 62,000 to 125,000 in New York State (NYS). ME/CFS affects more women than men and affects people of all socioeconomic backgrounds, age range, and ethnic and racial diversity. The IOM report estimated that as many as 84-91% of patients are not diagnosed.
The onset of ME/CFS is often sudden, typically following a viral or other type of infection but may occur following other types of physical trauma. In other cases, the disease may develop gradually. Patients describe feeling `flu-like’ symptoms chronically. In addition to the characteristic post-exertional malaise (PEM), patients may also experience cognitive impairment, unrefreshing sleep, autonomic manifestations, such as heart rate variability and excessive sweating, and also experience muscle and joint pain and sound, light, and chemical sensitivity. Elevated antibody titers to viruses may be present, in addition to low levels of autoimmune serology.
ME/CFS can present with a wide range of severity. Even in the same patient, the level of severity can change over time and from day to day as symptoms wax and wane. People with ME/CFS are unable to go about their daily activities in a predictable or consistent manner. The IOM report states that up to 70% of patients are unable to work and one quarter remain bed- or housebound (the latter however may be an underestimate). The IOM report also states that patients with ME/CFS are more functionally impaired than those with ”type 2 diabetes mellitus, congestive heart failure, hypertension, depression, multiple sclerosis, and end-stage renal disease.” Recovery is rare and as a result, patients can remain ill for decades.
Previously, ME/CFS was considered a diagnosis of exclusion but the IOM criteria provide for the presence of certain “core” criteria in order to make a diagnosis. The IOM clinical diagnostic criteria for ME/CFS require:
A number of co-morbidities can be seen in ME/CFS, the most common of which include fibromyalgia, postural orthostatic tachycardia syndrome (POTS), mast cell disturbances, and certain autoimmune disorders.
A noted above, there are no FDA approved treatments for ME/CFS. However, there are interventions that the physician can provide to help patients with this disease. First and foremost, the physician can explain PEM and the associated aerobic metabolism impairment. For some people, exertion as minor as tooth brushing or eating can trigger PEM and a crash. People with ME/CFS should not exceed their “energy envelope” and they should use an activity management approach called “pacing” to not exceed their limits. Physicians can also prescribe therapies that relieve symptoms, including those for sleep, pain, and orthostatic intolerance, including IV saline and Florinef. For patients with elevated viral titers, antiviral medications can help reduce symptoms. Patients often use earphones, earplugs, sunglasses, and eye masks to relieve sensitivities to light and sound.
Physicians can also support applications for disability. Social security accepts the 2-day CPET as objective evidence to support a disability claim. If this test is not easily available, a thorough explanation that describes the patients’ daily activities may suffice.
Physicians have an important role to play in the diagnosis and care of people with ME/CFS. In May 2017, NYS Commissioner of Health Dr. Howard Zucker sent a letter to physicians encouraging them to include ME/CFS as part of the differential diagnosis when evaluating patients with these symptoms. The clinical diagnostic criteria published by the Institute of Medicine (IOM) are an important tool and can result in faster and more accurate diagnosis. They can also provide the basis for treatment recommendations that can relieve symptoms and minimize post-exertional crashes. Most importantly, the physician can validate the patient’s experience and ensure that the patient is not harmed by inappropriate treatment recommendations.
Mary Dimmock is the parent of a son with ME/CFS. She is a biochemist by training and retired from the pharmaceutical industry. She is on the board of Solve ME/CFS Initiative.
Susan Levine, MD has been seeing ME/CFS patients in her clinical practice for over 30 years. She is Board Certified in Internal Medicine and Infectious Diseases and has served as past Chairperson of the Chronic Fatigue Syndrome Advisory Committee (CFSAC).
Terri L. Wilder, MSW is a volunteer with #MEAction (www.meaction.net) and was diagnosed with ME in March 2016. She received a Master’s in Social Work from the University of Georgia and currently manages a large clinical education program in New York City.
CMS Region II will be hosting a webinar at 4pm on February 22nd to provide basic information on how clinicians can submit their data successfully under QPP and MIPS to maximize their future reimbursement.
The webinar will also provide them with information on other resources that can help. As you know, those practices that are successful can receive significantly higher reimbursement from CMS in the future, but many clinicians still have questions and concerns and unsure about the upcoming deadlines or the technical assistance and resources.
MIPS Eligible Clinicians Can Now View Performance Scores for 2017 Claims Data on qpp.cms.gov
If you’re an eligible clinician who submitted 2017 Quality performance data for MIPS via claims, you’ll now be able to view your performance scores through the MIPS data submission feature. Reminder: claims data submission is only an option if you’re participating in MIPS as an individual (not as part of a group).
Submitting Quality Performance Data via Claims
If you’ve already submitted quality data via claims, you don’t have to take any additional action. Claims-based quality measures are calculated automatically by CMS based on the Quality Data Codes (G-codes) submitted on your 2017 claims. You can simply login at qpp.cms.gov and view your calculated individual measures' scores and category score for Program Year 2017.
Please note, scoring of claims data is subject to change monthly based on the processing of any additional 2017 claims and adjustments up to 90 days after the end of 2017. It is possible that claims or adjustments that were submitted towards the end of 2017 have not yet processed. Please check back after March 31st, 2018.
Still Time to Submit Claims for 2017
If you still have 2017 claims you’d like to submit for the Quality performance category, make sure to submit them now. Claims, which are processed by Medicare Administrative Contractors (MACs) (including claims adjustments, re-openings, or appeals), must get to the national Medicare claims system data warehouse (National Claims History file) by March 1, 2018 to be analyzed. The MACs can provide you with specific instructions on how to bill.
To prepare for 2017 submission, review the following resources on the Quality Payment Program website:
The Centers for Medicare & Medicaid Services (CMS) has identified an additional advancing care information identifier for use with the 2017 CMS Quality Reporting Document Architecture Category III (QRDA III) Implementation Guide (IG) Version 1.0 for Eligible Clinicians and Eligible Professionals Programs. The identifier ACI_IACEHRT_1 for Advancing Care Information Improvement Activities Bonus should be used when submitting for an ACI bonus for the use of certified electronic health record technology (CEHRT) for an improvement activity. An updated version of the 2018 CMS QRDA III IG will be published to reflect the addition of this identifier. This announcement is for vendors and data submitters about the additional identifier missing from the table ‘Advancing Care Information Objectives and Measures Identifiers’.
If you have not yet submitted QRDA III data to the Quality Payment Program for 2017 and need to account for the ACI_IACEHRT_1, you can simply include this measure identifier as part of your advancing care information section of your submission file.
If you have already submitted QRDA III data to the Quality Payment Program for 2017 and need to include the ACI_IACEHRT identifier, you can either:
Additional QRDA-Related Resources
You can find additional QRDA related resources, as well as current and past implementation guides, on the eCQI Resource Center and the CMS eCQM Library. For questions related to the QRDA Implementation Guides and/or Schematrons, visit the ONC QRDA JIRA Issue Tracker. For questions related to Quality Payment Program/Merit-based Incentive Payment System data submissions, visit the Quality Payment Program website or contact us by phone 1-866-288-8292, TTY: 1-877-715-6222 or email QPP@cms.hhs.gov.
On Tuesday, February 27, 2018 at 2:00 p.m. ET, the Centers for Medicare & Medicaid Services (CMS) will host a webinar that will provide an overview of QCDR measures development, processes and expectations. This webinar is intended to assist with the measure development of QCDR measures for future program years of MIPS. Please know that CMS is not accepting additional QCDR measure submissions for 2018.
Title: 2018 QCDR Measures Workgroup
Date: Tuesday, February 27, 2018
Time: 2:00-4:00 p.m. ET
Description: On Tuesday, February 27, 2018 at 2:00 p.m. ET, the Centers for Medicare & Medicaid Services (CMS) will host a webinar that will provide an overview of the development, criteria, and evaluation of QCDR Measures. Among the topics to be presented during the webinar, CMS will provide information regarding:
Audience: Current and Prospective Qualified Clinical Data Registries
Event Registration: https://engage.vevent.com/rt/cms/index.jsp?seid=1003
The audio portion of this webinar will be broadcast through the web. You can listen to the presentation through your computer speakers. If you cannot hear audio through your computer speakers, please contact CMSQualityTeam@ketchum.com. Phone lines will be available for the Q&A portion of the webinar.
For More Information
CMS Will Answer Questions about MIPS Submission Feature During Three “Office Hours” Sessions
Deadlines are fast approaching to submit data for the 2017 Merit-based Incentive Payment System (MIPS) performance period. The 2017 submission period runs through March 31, 2018 with two exceptions:
1. Groups using the CMS Web Interface have until March 16, 2018 at 8pm ET to submit data.
2. Individual Eligible Clinicians submitting quality data via claims, must submit claims by March 1, 2018.
To help individual eligible clinicians and groups prepare for submission, CMS will be hosting three “Office Hours” sessions over the next several weeks. CMS subject matter experts will answer commonly asked questions about the submission feature on qpp.cms.gov, as well as answer attendees’ questions live. Registrants will also have the opportunity to email their questions prior to the sessions.
Review the Office Hour topics and register below. Please note that Qualified Registries, Qualified Clinical Data Registries and Web Interface Reporters should utilize their support calls for data submission support.
Date: February 14, 3:30-4:30pm ET
Title: Quality Payment Program Data Submission Office Hours: Individual Eligible Clinician and Group Submission
Date: February 28, 3-4pm ET
Title: Quality Payment Program Data Submission Office Hours: MIPS Quality Data Submission
Date: March 14, 3-4pm ET
Title: Quality Payment Program Data Submission Office Hours: MIPS Attestation for Advancing Care Information and Improvement Activities
Please note: Space for these sessions is limited. Register now to secure your spot. The audio portion of the sessions will be broadcast through the web. You can listen to the presentation through your computer speakers.
For step-by-step instructions on how to submit MIPS data, check out this video and fact sheet. Questions about your participation status or MIPS data submission? Contact the Quality Payment Program Service Center by:
Deadlines are fast approaching if you plan to submit data for the 2017 Merit-based Incentive Payment System (MIPS) performance period. Don’t wait until the last minute to submit your data. Submit early and often. The two key dates are:
Now is the time to act. Here are the top 10 things you need to do and know if you are an eligible clinician. This list focuses on reporting via the qpp.cms.gov data submission feature, not on group reporting on via the CMS Web Interface and not on individual reporting on Quality measures via claims submission data.
Note: If you’re not sure if you are required to report for MIPS, enter your National Provider Identifier (NPI) in the MIPS Lookup Tool to find out whether you need to report. Additionally, if you know you are in a MIPS APM or Advanced APM, you can use the APM Lookup Tool.
If you are in an ACO or other APM, make sure you are working with your ACO or APM to make sure they have any patient information they need to report. Remember you need to report on Advancing Care Information measures on your own.
Questions about your participation status or MIPS data submission? Contact the Quality Payment Program Service Center by:
Southern Tier Lyme Support, Inc and Binghamton University are offering 5.5 CME credits through Upstate Medical to physicians (MD and DO) at this years Southern Tier Lyme Conference.
Registration for the May 5th conference at Binghamton University will open for medical professionals starting 2/15/2018 at www.southerntierlymesupport.org. The cost of the conference is $75 for physicians and $5 for all other medical professionals and the public.
Thursday March 29, 2018
7:30 a.m. - 4:30 p.m.
125 E. Main St.
Rochester, NY 14604
For more information and to register: www.starrochester.com
Agenda highights advances in regional systems of care for stroke patients
Who Should Attend
This activity is intended for primary care physicians, internists, neurologists, neurosurgeons, emergency physicians, family physicians, radiologists, cardiologists, nurses, physician assistants, nurse practitioners and EMS personnel who care for patients with cerebrovascular disorders
At the conclusion of this activity participants should be able to:
$100 early registration, $150 after March 16th,
Students: $50 early registration, $75 after March 16th