The AAFP is staying on top of CMS' efforts to create new patient relationship codes that will be used to help determine incentive payments as part of the Medicare Access and CHIP Reauthorization Act (MACRA).
CMS is required by MACRA to create codes aimed at identifying attributed resource use by physicians; the agency has been crafting and tweaking those since mid-2016, and the AAFP has been an active participant in reviewing and commenting on that work.
The AAFP's latest action on the issue came late in December via a letter to CMS Acting Administrator Andy Slavitt(3 page PDF) -- signed by AAFP Board Chair Wanda Filer, M.D., M.B.A., of York, Pa. -- that responded to CMS' online posting of a revised list of patient relationship categories and codes.
The Academy was blunt in its overall assessment of the agency's changes: "We continue to have grave concerns that this reporting requirement will significantly increase the administrative burden that Medicare-participating physicians already experience."
The letter repeated an earlier request from the AAFP that CMS provide more details on how the patient relationship categories and codes would be used to attribute cost and patient outcomes to physicians, as well as how the information would be used with episode groups.
The AAFP urged CMS to "thoroughly pilot test" the proposed categories before committing to using them because of the impact on physician payment.
"CMS must 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," said the letter.
The AAFP also answered three questions CMS had posed to invite feedback that would assist in its rulemaking efforts.
The first question asked whether the draft patient relationship categories -- which CMS based on the dual axes "continuous/episodic" and "broad/focused" -- were clear enough to enable clinicians to consistently and reliably self-identify an appropriate patient relationship category for a given clinical situation.
The AAFP agreed that the categories would enable most physicians to effectively describe their relationship to a patient and noted that the new categories were a "vast improvement" compared with those originally created by the agency. Family physicians typically have a "continuous/broad relationship with their patients," noted the letter.
The Academy urged CMS to "further define and thoroughly educate physicians and their staff about these coding changes before these new codes are required."
Given the variety of settings in which physicians and other health care professionals provide patient care, CMS also wanted to know whether the draft categories would be capable of capturing the majority of patient relationships for clinicians.
The AAFP again expressed support for "classifying relationships using the dual (axes) of 'continuous/episodic' and 'broad/focused'" and gave two examples of the flexibility of those terms in describing a wider range of clinician roles: family physicians acting as hospitalists could accurately classify their patient relationships as "episodic/broad," while those serving as emergency department physicians would likely describe their patient relationships as "episodic/focused."
"Pilot testing utilizing these relationship categories should involve physicians from all specialties providing care across a variety of care settings because these relationship categories will impact analysis of physician resource use and cost within value-based payment reimbursement models," cautioned the AAFP.
Lastly, CMS queried stakeholders as to whether Healthcare Common Procedure Coding System modifiers were the appropriate mechanism for CMS to use as it works to include the patient relationship category on Medicare claims.
The AAFP agreed with this approach given family physicians' experience using the A1 modifier since consultation codes were discontinued in 2010.
"Family physicians will quickly learn to use new modifiers for reporting patient relationship categories," said the AAFP, but added that CMS "must notify and educate physicians well in advance" of when the modifiers are required.
The Academy also advised CMS that physicians would need ample time to train their office staff members and asked the agency to provide detailed training vignettes to assist in those education efforts.