The AAFP recently gave CMS frank feedback detailing how the agency should rework a proposal to create new patient relationship codes that may help determine incentive payments under the Medicare Access and CHIP Reauthorization Act (MACRA).
MACRA requires that CMS create the codes to help attribute resource use by physicians. The agency drafted principles and patient relationship categories that might serve as a foundation for the codes and then invited comments on those elements.
CMS proposed three patient relationship areas: continuing care, acute care, and acute care or continuing care. Furthermore, the first two areas would each be split into two categories. Continuing care would typically represent the role of primary care physicians, and the other patient relationship areas are more likely to represent the roles of other physicians, such as hospitalists and subspecialists. CMS acknowledged that distinguishing physicians based on their relationship with a patient at any one time will be complicated.
- CMS is planning to create new patient relationship codes that could help determine Medicare incentive payments.
- The three patient relationship categories are continuing care, acute care, and acute care or continuing care.
- In a letter urging CMS to rework its proposal, the AAFP pointed out that because family physicians often handle multiple conditions in a single patient, selecting one choice in the patient relationship category is difficult.
In an Aug. 12 letter(6 page PDF) to CMS Acting Administrator Andy Slavitt, AAFP Board Chair Robert Wergin, M.D., of Milford, Neb., expressed the Academy's continued support for MACRA while calling on the agency to provide more clarity about how relationship categories and their associated codes will be used. They should be implemented with the goal of minimizing physicians' reporting burden and avoiding unintended consequences, especially for small practices, Wergin wrote.
"The AAFP has grave concerns that the direction CMS is going with the categories it describes is inconsistent with these principles and will simply 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," he wrote.
Wergin noted that the proposed relationship areas are not distinct enough to allow physicians to select the appropriate one. For instance, the continuing care relationship area has one category describing a clinician who is the primary care provider and a second describing a clinician who provides specialized care. As written, a family physician could fit into either category. Family physicians often handle multiple conditions in a single patient, so selecting one patient relationship category would be difficult.
"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," Wergin wrote. "When applying patient relationship codes to encounters, there could be confusion if the clinician has different relationships based on the patient's different diagnoses."
Physicians already have a difficult time with multiple codes on claims. Adding a complicated new variable to identify a patient relationship would require physicians and their staff members to devote substantial time to learning proper coding for written forms and electronic health records.
CMS asked pointedly whether its proposed categories were clear enough, and the AAFP responded that they are not.
"The proposed patient relationship categories have the potential to capture care relationships in a variety of settings," Wergin wrote. "However, we are not convinced that the proposed categories are sufficiently clear and distinct to ensure that they will be validly and reliably used by physicians."
CMS will not require patient relationship codes on claim forms until 2018, so the process remains in the planning stages. The AAFP is pushing for a pilot testing period and significant education tools to help physicians adjust to the new codes before they become a requirement.
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