Industry Groups Call on CMS to Modify MACRA Patient Codes

September 02, 2016 - Proposed patient relationship codes that will be used under MACRA to measure appropriate resource use and determine value-based reimbursement adjustments may cause more confusion for providers and increase administrative burdens, according to the American Academy of Family Physicians (AAFP).

“We strongly urge CMS to provide additional information on how these patient relationship categories and codes will be used to attribute cost and patient outcomes to physicians and also how this information will be used related to episode groups,” the organization wrote to CMS earlier this month. “It will be essential for CMS to pilot test thoroughly these patient relationship categories before their use impacts payments.”

“The AAFP calls on CMS to minimize the reporting burden for physicians and for the agency, through pilot testing, to address logistical issues and possible unintended consequences, especially for small practices,” the letter added.

Under MACRA, CMS proposed several classification code sets to evaluate the resources used to provide care to patients. As part of the resource use assessment, the federal agency established patient relationship codes to track what providers cared for a patient at the time of furnishing a service or item and distinguish what type of care was provided, such as acute or non-acute care.

CMS developed three patient relationship areas, including continuing care, acute care, and acute care or continuing care. Each area contains a list of relationship codes that range from primary care providers who are responsible for coordinating care to clinicians who are furnishing services based on another provider’s orders.

Providers would be required to submit a patient relationship code at the time of medical billing if they are eligible to participate in the Merit-Based Incentive Payment Program. The codes would show each provider’s level of care responsibility and the healthcare costs of the providing care. CMS would then use the information to determine value-based reimbursement adjustments for each eligible clinician.

However, AAFP stated that the codes would “lead to more ‘administrivia’ for physicians, will not achieve the intended aim of facilitating resource use allocation among physicians and will not lead to better outcomes of care.”

For many providers, AAFP argued, the codes may be confusing because they frequently provide care for patients for multiple health conditions in a single encounter and their relationships with patients may be more fluid.

“Patient relationship categories must be mutually exclusive in a given situation, so a physician does not have to choose among two or more equally applicable categories for a patient in a particular circumstance,” the letter stated.

The codes may be especially problematic for family physicians, AAFP added, because their role oftentimes shifts across the established patient relationship categories. For example, a family physician may be the primary care provider in a continuity relationship as well as a specialist who manages health conditions, such as diabetes and heart disease, in an acute episode. Family physicians are also sometimes asked to consult on patients that have been hospitalized during an acute episode.

“[W]hen applying patient relationship codes to encounters, there could be confusion if the clinician has different relationships based on the patient’s different diagnoses,” wrote AAFP. “Without more knowledge of how patient relationship codes will be used and applied, it is difficult to comment on which level of association would be most appropriate for the given use case.”

The organization also stated that patient relationship codes could have a negative impact on healthcare revenue cycle performance. CMS should further educate providers on how to submit the codes as well as where the federal agency plans to designate a place for the code, such as in certified EHRs or on claim forms.

Proposed patient relationship codes could also put pressure on medical billing staff since it is not always clear what provider submitted information in the medical record and headers tend to be unreliable for tracking users.

“No matter how well-trained coders are, they cannot be responsible for determining who has assumed liability for a patient, which is often subject to litigation in medical liability cases,” the letter stated. “The determination must be made by the clinician providing the services.”

The organization voiced concerns that “CMS could cause serious disruptions in claims generation when physicians have to be queried to make this determination.” Since relationship determinations are connected to resource use and value-based reimbursement amounts, some providers may be hesitant to tie their name to high-cost patients. As a result, providers could see slower claims generation.

Additionally, the American Society for Radiation Oncology (ASTRO) penned a letter to CMS expressing how cancer specialists may also face confusion with determining the most appropriate code for specialists.

“We believe that oncologists, radiation oncologists and others, will not be able to consistently and reliably self-identify the appropriate patient relationship category because of what is often the multidisciplinary approach to cancer care,” the industry group wrote.

“The proposed categories only allow for a single provider to serve in the lead role for a patient’s care; all other providers would serve in the secondary or consulting provider roles,” continued the letter. “This fails to account for the multidisciplinary and team-based approach often used for providing care, particularly in cancer care.”

ASTRO advised CMS to create a new patient relationship category or code that addresses the use of care coordination and a multidisciplinary team approach for acute and continuing episodes of care. Alternatively, the group recommended to allow more than one provider to identify as the primary provider for a patient’s care.

With the comment period on patient relationship codes closing last month, CMS plans to review the submissions and finalize any additional changes to the rule.

Dig Deeper:

• How MACRA, MIPS Will Impact Critical Access Hospitals, FQHCs

• What We Know About Value-Based Care Under MACRA, MIPS, APMs