January 5, 2017
As part of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, the Centers for Medicare and Medicaid Services (CMS) established a new Quality Payment Program (QPP) designed to tie physician payments to quality and value. Under QPP, physicians not participating in advanced alternative payment models (APMs) are eligible for the Merit-Based Incentive Payment System (MIPS) which combines traditional fee-for-service (FFS) base payments with payment adjustments based upon physician performance across four categories:
- Advancing Care Information (ACI)
- Improvement Activities (IAs)
- Resource Use
A detailed analysis of what MIPS means to radiologists can be found here. Based on the MACRA statute, CMS provides special considerations under MIPS for clinicians determined to be non-patient facing. These non-patient facing considerations include “exemption” from, that is re-weighting to zero, the ACI category – which supplants CMS’ previous EHR Incentive program, known as “meaningful use” – and a reduction in requirements by half in the Improvement Activities category. For small and rural practices, CMS reduced the number of required improvement activities to one high-weighted or two medium-weighted activities. More information on MACRA and small and rural practices can be found here.
The effect of the non-patient facing determination has particular impact on the ACI category, as these measures are difficult for radiologists to meet. As a result, it is important to understand under what conditions a radiologist would be defined as non-patient facing and thus automatic reweighting of the ACI category so that it would not factor into their MIPS total score. Additionally, radiologists should understand that they may also have the ACI category reweighted to zero automatically based on status as a hospital-based clinician. Thirdly, radiologists may meet other criteria, for which manual application is needed, to have the ACI category reweighted to zero. More information on reweighting ACI can be found here.
CMS initially proposed that physicians would be designated as patient facing if they had more than 25 patient facing encounters during the reporting period. After incorporating feedback from the American College of Radiology (ACR) and subsequent analysis by the Neiman Institute, CMS’ final rule stated that physicians would need more than 100 patient facing encounters to be designated as patient facing and subject to these additional performance criteria. However, the final list of Current Procedural Terminology (CPT) codes used to determine patient facing encounters was not available in conjunction with the proposed and final CMS QPP rules and was to be released at a later date.
On Dec. 29, 2016, CMS posted a fact sheet and the list of CPT codes that would be used to determine the patient facing designation:
“For purposes of the 2019 MIPS payment adjustment, CMS will initially identify individual MIPS eligible clinicians and groups who are considered non-patient facing MIPS eligible clinicians based on 12 months claims run out. In order to account for the identification of additional clinicians and groups that may qualify as non-patient facing during the 2017 performance period, it will conduct another eligibility determination analysis based on 12 months of data starting from September 1, 2016 to August 31, 2017 with a 60-day claims run out. This timeline will allow CMS to inform clinicians and groups of their non-patient facing status during the month (December) prior to the start of the performance period.
All MIPS eligible clinicians who meet the definition of a non-patient facing MIPS eligible clinician will be considered non-patient facing for the duration of a performance period. Furthermore, a clinician who identified as non-patient facing during the first eligibility determination analysis will continue to be considered non-patient facing for the duration of the performance period regardless of the results of the second eligibility determination analysis.”
Now that the final list of CPT codes has been released, we are able to explore how radiologists will be affected by CMS’ patient facing designation. Working with Judy Burleson, ACR’s Senior Director for Quality Management Programs, and our own Wenyi Wang, we used CMS’ Physician and Other Supplier Public Use File for 2014 to examine how many radiologists would be designated as patient facing using CMS’ definition. Among other data elements, the publicly available Physician and Other Supplier data contain 100 percent of all Medicare FFS performed and aggregated by CPT code and individual physician. This allows us to calculate exactly how many “patient facing encounters” each radiologist billing Medicare FFS claims had in 2014:
As we see, 10 percent of all radiologists and 9 percent of diagnostic radiologists would receive the patient facing designation under CMS’ definition. I should note that the Physician and Other Supplier data cover services from January 1-December 31, as opposed to the September 1-August 31 period that CMS will actually use for the determination. Unfortunately, the data doesn’t allow us to match CMS’ time period. However, we expect most 12 month periods to be consistent. As a robustness check, we calculated how many radiologists would receive the patient facing designation for each year the Physician and Other Supplier data is available:
Looking at this table, the number of physicians designated as patient facing is fairly consistent over time. Therefore, we have no reason to believe that the September 1-August 31 measuring period will vary much from these calendar year results.
An important consideration for radiologists when determining how they can best comply with MIPS is to remember that even if they are personally designated as patient facing, their group may still have the ACI category reweighted to zero and reduced IA requirements if their group (designated by the group Tax Identification Number) reports under the group reporting option. Under the group reporting option, if 75 percent of a group’s clinicians meet the non-patient facing criteria then the group does as well.
To help radiologists understand whether they – or their practice – are likely to be designated as patient facing for participation in MIPS, the Neiman Institute has provided the Radiologist Patient Facing Dataset on its website. With this dataset, prepared using the publicly available Physician and Other Supplier data, radiologists can look up whether they would have been designated as patient facing by CMS in 2012-2014. By looking up all of the radiologists in their practice they can also determine whether they are likely to be exempt under MIPS’ group reporting option. Using this and other Neiman Institute online data tools, radiologists can prepare and succeed in CMS’ evolving payment models.