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The CAP has asked the Centers for Medicare & Medicaid Services (CMS) to further clarify a recent request for information related to patient relationship categories and codes to be developed under the new Merit-Based Incentive Payment System (MIPS). Specifically, the CAP is asking CMS to provide greater detail on use of codes before finalizing code descriptors and to provide definitions of terms used in the proposal.

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) required the establishment and use of classification code sets: care episode and patient condition groups and codes, and patient relationships categories and codes. Physicians will have to include the newly developed codes on their claims as of January 1, 2018, if they choose to participate in MIPS. The CMS expects to post a draft list of codes for groups in early November.

On April 15, the CMS posted the patient relationship categories for public comment. The relationships fall into three categories:

  • continuing care relationships (such as primary care physicians)
  • acute care relationships (such as a hospitalists or an emergency room physicians)
  • acute care or continuing care relationship (non-patient facing clinicians such as pathologists)

Within those categories, the CMS describes five physician or practitioner types ranging from one who has the primary responsibility for the general and ongoing care for the patient over extended periods of time (I) to one who furnishes items and services to the patient on an occasional basis, usually at the request of another physician or practitioner (IV) to one who furnishes items and services only as ordered by another physician or practitioner (V).

The CMS asked whether the draft categories are clear enough and whether it makes sense to include a relationship category that is specific to non-patient facing clinicians.

In an August 15 response to the CMS, the CAP stated it cannot provide detailed comments on the draft patient relationship codes without fully understanding how they will be used. "In general, the CAP does not believe the draft patient relationship codes are sufficient or that the categories of acute and chronic care represent the full range of relationships between patients and physicians," the CAP stated. "The CAP believes the code descriptions need to relate to how the codes will be applied (e.g., once per claim similar to Place of Service or different codes for each CPT code). The CAP suggests that it may be easier to have a default patient relationship code based on specialty and only exceptions indicated on claims via the use of a CPT modifier."

Whatever descriptor and mechanism the CMS decides to use, the CAP recommends that the agency perform pilot testing to assure the patient relationship codes work as intended.

Simpler and Clearer

In its comments, the CAP stresses that the categories need to be simpler and clearer. "For the most part, the categories need more definite dividing lines so as to avoid the potential confusion…Many of CAP members thought IV vs. V were overlapping and confusing. It is not clear which types of practices CMS is trying to distinguish between these two categories."

In response to whether the CMS should include a patient relationship category that is specific to non-patient facing clinicians, the CAP also notes that it is not clear how specifying non-patient facing will be used in the context of measuring resource use.

"Category V seems to cover pathologists, but perhaps they could specifically state it is for PRIMARILY non-patient facing clinicians," the CAP said. "The risk of miscoding the relationship would seem greater when the pathologist isn't identifying it, but appropriate technical assistance and education…could minimize that risk. Finally, as we understand the patient relationship codes, there would not be a single patient relationship that would accurately characterize all services provided by non-patient facing clinicians."

The CAP will continue to engage with the CMS to determine how to measure appropriately the resource use of providers who typically do not furnish services that involve face-to-face interaction with patients, including pathologists.

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Registration is now open for key CAP policy and advocacy courses and roundtable discussions important to the pathology specialty during CAP16 in Las Vegas September 25-28.

Ensure you can attend "MACRA, Pay for Performance and the Physician Fee Schedule—You Can Run But You Can't Hide" (S1620) by registering and selecting this popular course today. Enactment of the Medicare Access and CHIP Reauthorization Act (MACRA) will change how all physicians are paid under Medicare. Make sure to attend this course and learn about this game changing mandatory Medicare physician payment system. Measurement periods begin in 2017 so register now so that you are ready for these changed to Medicare's physician reimbursement system.

During this featured presentation, attendees will learn the purpose of new pay-for-performance programs and delivery system reform culminating in the enactment and implementation of MACRA. Experts will explain which pathologists are subject to, and ways to successfully participate in, the merit-based incentive payment system and alternative payment model pathways. The potential ramifications for not participating will also be discussed.

The session starts at 8 AM on Monday, September 26. Register for S1620 MACRA, "Pay for Performance and the Physician Fee Schedule—You Can Run But You Can't Hide" today.

Additional CAP advocacy courses and roundtable discussions are also available at CAP16:

  • M1597 "How is My Payment Determined for Pathology Services?"
    Sunday, September 25, 4:30-5:30 PM
  • R1690 "My Surgical Pathology and Cytopathology Coding Dilemmas: Getting It Right"
    Monday, September 26, Noon-1 PM
  • STA001 "How Data Drives CAP Advocacy: What Pathologists are Saying about the Economics of Pathology Practice"
    Monday, September 26, 5:30-6:30 PM
  • R1691 "Current Payment Policy Challenges in Pathology Practice"
    Tuesday, September 27, Noon-1 PM

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