Life Science Compliance Update

August 11, 2017

MACRA Categories and Codes in CMS Proposed Fee Schedule


In the 2018 proposed Medicare Fee Schedule rule, CMS reviews MACRA patient relationship categories and codes, their development and timelines, and provides details for the initial claims-based reporting of the relationship categories and codes to CMS.


Section 101(f) of MACRA added a new subsection (r) to section 1848 of the Act entitled Collaborating with the Physician, Practitioner, and Other Stakeholder Communities to Improve Resource Use Measurement. Section 1848(r)(2) requires the development of care episode and patient condition groups plus group classification codes. To satisfy the purpose of patient and/or episode attribution to one or more clinicians, it further requires:

  • The categories and codes must define and distinguish an applicable practitioner’s relationship to and responsibility for each patient when an item or service is furnished to the patient by that practitioner.
  • The categories shall include different potential practitioner-patient relationship types.
  • The categories shall reflect various potential responsibility types.
  • The categories shall capture the frequency with which the practitioner delivers care to the

Patient Relationship Categories

CMS posted and solicited public comment upon a draft relationship categories list and the list’s foundational principles in April 2016. Potential category modifications were developed based upon comments received. In December 2016, CMS sought comments about such modifications and about operational approaches for reporting the categories on Medicare claims. After comment review, CMS posted the first operational list of patient relationship categories on May 17, 2017:

  • Continuous/Broad Services,
  • Continuous/Focused Services,
  • Episodic/Broad Services,
  • Episodic/Focused Services, and
  • Only as Ordered by Another Clinician.

Patient Relationship Reporting Using Modifiers

Section 1848(r)(4) of the Act specifies that claims for services furnished beginning January 1, 2018, shall include, as determined appropriate by the Secretary, the following:

  • Any applicable codes for care episode groups,
  • Any applicable codes for patient condition groups,
  • Any applicable codes for patient relationship categories, and
  • The NPI of the ordering physician or applicable practitioner.

CMS describes having planned to use procedure code modifiers for patient relationship code reporting via claims. In December 2016, commenters indicated a preference for CPT modifier codes rather than HCPCS Level II modifiers. CMS submitted a CPT code application that was rejected in June 2017, as the CPT Editorial Panel preferred to wait until the proposed modifiers were finalized before issuing Category I CPT codes. CMS is therefore proposing HCPCS modifiers as shown in Table 26 reproduced from the proposed rule:

Proposed Patient Relations HCPCS Modifiers and Categories


Proposed HCPCS Modifier

Patient Relationship Categories



Continuous/Broad Services



Continuous/Focused Services



Episodic/Broad Services



Episodic/Focused Services



Only as Ordered by Another Clinician

CMS proposes that claims for services furnished beginning January 1, 2018, shall include the appropriate modifier selected from Table 26 and the NPI of the ordering practitioner. CMS proposes that modifier reporting will be voluntary. Modifier use would not be a condition of payment, affect payment, change the meaning of a reported procedure code(s), or be tied to any reported E/M service(s) intensity. The duration of the voluntary HCPCS modifier reporting period is not specified by CMS. Finally, CMS notes that the relationship codes may be incorporated into future QPP measures. CMS seeks comment on the proposed modifier list, the plan to resubmit the modifiers for CPT code assignments, and the initial voluntary reporting of the proposed modifiers.

July 03, 2017

CMS Releases 2016 Open Payments Data


2016 Open Payments Data was released on Friday, June 30, 2017. In 2016, the total dollar amount of payments totaled $8.18 billion. The total amount of general payments made amounted to $2.80 billion; the total amount of research payments amounted to $4.36 billion; and the value of ownership or investment interest totaled $1.02 billion.

Where Did The Money Go?

The $8.18 billion was given to 631,000 clinicians and 1,146 teaching hospitals. Drug and device makers are required to report any “transfer of value” of $10 or more, or transfers of value that add up to more than $100 per year.

Roughly 75% of the $2.8 billion ($2.07 billion) in general payments went to clinicians, including physicians, dentists, optometrists, podiatrists, and chiropractors. Teaching hospitals received $724.51 million in general payments.

Research payments largely went to teaching hospitals: $867.95 million, compared to the $95.21 million that went to physicians. The physician research payment total includes payments where the company making the payment has named a physician as the primary recipient, as well as payments to a research institution or entity where a physician is named as a principal investigator on the research project.

Year to Year Comparisons

The below tables show comparisons of different data points over the past few years.


The above table compares the percent change in total payments and records. The percent change in payments and interest from 2015 to 2016 totaled 1.11% ($8.09 billion to $8.18 billion).


The above table compares the percent changes in three different payment categories: general payments (4.5%); research payments (-2%); and ownership interest (6.3%).


The above table compares the 2014 to 2016 change in number of companies reporting (-8.24%); physicians receiving payments (.96%); and teaching hospitals receiving payments (1.69%).

Medscape joined the “fake news” craze, by stating the increase was 8.8% from last year’s payments. However, the actual rise was less than 1.1%.


Visitors to the CMS Open Payments website can look up individual clinicians and hospitals to see what they have received from drug and device makers and compare their payments to national and specialty averages.

June 22, 2017

MACRA Letters Went Out, Finally


The Centers for Medicare and Medicaid Services (CMS) finally mailed out letters to medical practices, providing clinicians with their participation status in the Merit-based Incentive Payment System (MIPS). MIPS is one of two payment tracks within the Medicare Access and CHIP Reauthorization Act (MACRA). The letters were supposed to go out in December, but that deadline came and went without any letters mailed. Roughly 419,000 providers were notified that they are participating in MIPS and must meet the reporting requirements for 2017. CMS uses historical claims data and data from the performance period to make the determination whether or not a physician/other healthcare provider is eligible for MIPS participation.

Meanwhile, there were over 800,000 providers who received the news that they do not need to participate in the MIPS program this year. Physicians are exempt from MIPS participation if they have less than $30,000 in Medicare charges and less than 100 Medicare patients per year. Additionally, physicians who are new to Medicare this year are also exempt.

Depending on whether a particular medical practice reports as a group, even physicians who do meet those exemption requirements may be required to participate. If the medical practice reports as a group all of the providers within the group’s Tax Identification Number (TIN), all providers will be included, even if an individual provider falls below the minimum thresholds above. Additionally, if providers participate in more than one TIN, they will need to verify their reporting status with each practice.

The number of clinicians who will participate in MACRA overall, however, will be higher than the estimated 419,000 participating in MIPS. The others will participate via alternative payment models (APMs). CMS expects that more physician practices will participate under MIPS as opposed to APMs, as MIPS allows the greatest financial reward, but also requires the doctors to take on more risks.

The number of MIPS participants differed from estimates made in the MACRA final rule released last fall, based on an updated eligibility formula. Under MIPS, physicians will receive Medicare payments based on quality measures and their use of electronic health records.

The letter provides instructions on what steps MIPS participants need to take, as well as reinforces deadlines to help physicians avoid a four percent negative payment adjustment for not participating. The letter also comes with an attachment with additional participation information and a list of frequently asked questions.

Physicians still unsure if they must participate in MIPS can visit, click on the MIPS Participation Look-up Tool and use their National Provider Identifier (NPI) to check their status. The look-up tool can also be helpful to practice administrators or clinicians who did not personally view the letter mailed because it was received by administrative leaders or a corporate office.


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