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MIPS/Advanced Alternative Payment Models and CMS New Patient Relationship Codes

MACRA: Identifying the Provider-Patient Relationship

By now, you have heard of the Medicare reform terms associated with the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA), namely the merit-based incentive payment system (MIPS) and advanced alternative payment models (A-APMs). Beginning in 2019, physicians, physician assistants, nurse practitioners, clinical nurse specialists, and CRNAs paid under a Medicare Physician Fee Schedule (MPFS) will be subject to one of these two new payment methodologies based on measured performance in the preceding two years (2017 for a 2019 payment year). Simple enough, right?

Well, the devil is always in the details. Each year the Center for Medicare & Medicaid Services (CMS) releases those details in the form of a rule/regulation that can be quite complex and hundreds of pages long. On July 13, 2017, the 2018 CMS MPFS proposed rule was released. This 800+ page rule includes expanded coding on claims to identify the relationship between the provider and the patient for purposes of payment and adjustments under MIPS and A-APMs.

New Data for New Measurements

In just 95 pages of legislation, MACRA mentions the term “measure” and “measurement” over 170 times; and, the term “data” over 100 times. In other words, MACRA is all about measuring care delivery and resource use using data. Over time your Medicare payments will be based on how you measure-up on data reported to CMS, particularly claims.

Remember that CMS is a payer and the most fundamental data source payers have today is claims.  Providers typically consider their claims process as a means of getting paid. True. Yet, clinicians need to undergo a crucial mental shift to position for value-based payment. Understand that your claims process is actually a reporting vehicle. It always has been. Claims represent your means of communicating the nuances associated with the patients you treat to the organization that pays you. All payers use this information extensively to understand the burden of disease, patient complexity, and to stratify risk associated with the patients they cover.

Codifying the Patient Relationship

Under MACRA, this claims data is undergoing an expansion. MACRA requires CMS to address operational needs associated with MIPS and A-APMs administration by way of defining 3 new code sets for use on claims. The first code set they have been working on is known as “patient relationship codes.” Your relationship to the patient will be categorized and reported through claims beginning in January 2018 using Level II HCPCS Modifiers.

To start, the proposed rule is planning to make reporting “voluntary” and not a condition of payment. CMS plans to use these codes to attribute patients and episodes (in whole or in part) to one or more physicians/clinicians. This information will allow CMS a systematic means of distinguishing the patient-clinician relationship to look at plurality of care, whether items/services are delivered as acute or non-acute, and to pin-point resource use (cost) during a care episode or for a patient condition.

Specifically, the CMS rule is looking to finalize 5 categories of patient relationship codes, as follows:

Table 26 in the proposed rule identifies the modifiers that are associated with these relationship categories. These modifiers will represent the machine-readable fashion in which your relationship with your patient can be communicated on a claim, namely:

Positioning for the Future

Today, identifying your relationship with the patient will not impact your payment. It is not something you think about as you practice medicine. MIPS and A-APMs are challenging clinicians to think beyond individual patient interaction to approach care as a team with others with whom a patient is shared, such as a hospitalist, a specialist, or an ancillary provider.

While in the short-term these codes are not required nor will they impact your Medicare payment, over time you will find this coding to be necessary for traditional Medicare patients under MACRA. Long-term, we expect you will see these code sets enter mainstream and have a direct impact on provider economics under new and emerging value-based payment models industrywide.

Your future is all about the data you create. The strongest positioning a practitioner can have is strong improved documentation, especially through the use of structured data on your claims. This is the easiest way to improve your performance today.

Adele Allison
Director of Provider Innovation Strategies
DST Health Solutions, LLC
Birmingham, AL

Published on 9/27/17


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