The Reading Room

What to do with CMS's new patient-facing encounter codes

by Pooja Desai

CMS recently published a list of patient-facing encounter codes that will affect which reporting requirements and performance metrics apply to clinicians within the Merit-Based Incentive Payment System (MIPS) under MACRA. This list of encounter codes helps radiologists gain clarity on what performance metrics they will be evaluated on under MIPS.

Quick refresher: MIPS for patient-facing and non-patient-facing physicians

MIPS reporting requirements and performance categories are weighted differently for patient-facing and non-patient-facing clinicians. Notably, for non-patient-facing clinicians, the cost category within MIPS is weighted at zero, and reporting requirements for clinical improvement activities are cut in half. As a result of this re-weighting, these physicians experience a greater emphasis on quality.

MIPS performance metrics and reporting requirements

Resource Use
Clinical Practice Improvement
Advancing Care Information
Six measures including one outcomes measure, or one specialty measure set
Based on claims, so no reporting; includes 10 episode-based costs and total costs per beneficiary
Four medium-weighted or two high-weighted measures
Five required measures
Same as patient-facing requirements if possible; if not, as many as possible
Category weighted at zero
Two medium-weighted or one high-weighted measure
When enough measures are not applicable or available, category weighted at zero

What "patient facing" means

Since the definition of non-patient-facing clinicians in the initial MACRA proposal was written in a way that excluded many radiologists, there were concerns that the full set of MIPS performance metrics put forth did not take their unique needs into account.

However, in the final rule, the definition of non-patient-facing physicians was revised and broadened for both providers and groups as follows:

  • Non-patient-facing MIPS-eligible clinician: An individual who bills 100 or fewer patient-facing encounters annually.
  • Non-patient-facing MIPS-eligible group: A group in which at least 75% of eligible providers are designated as non-patient-facing clinicians.

To determine which providers qualify for non-patient-facing status, CMS will use Medicare claims from two twelve-month time periods, with the first beginning September 1 two years prior to the performance year. Providers and groups will only be deemed patient facing if they exceed the thresholds for two consecutive assessment periods.

Non-patient-facing determination timeline for the 2017 performance year (PY)

determination timeline

Two tools for leveraging the list of patient-facing encounters

With the list of patient-facing encounter codes now available, the Neimen Institute predicts only 10% of all radiologists will be considered patient facing. However, nearly 54% of interventional radiologists are expected to fall under the patient-facing designation. When determining how to best comply with MIPS, organizations must consider the percentage of interventional radiologists and procedure-driven diagnostic radiologists present in their group and the volumes of codes they bill for.

Having a firm grasp of these statistics will be essential to making these informed decisions. That's why we've identified two key resources that will help you and your program determine which designation fits best.

  1. Radiologist Patient-Facing Dataset. Prepared by the Neimen Institute, this dataset allows radiologists to look up whether they would have been considered patient-facing clinicians by CMS in 2012-2014. Radiologists can also search colleagues in their practice to determine whether MIPS' group reporting would grant exemption.

  2. Complete Dataset of Patient-Facing Encounters. The original document by CMS may be of use if you are a member of a multi-specialty practice. Organizations may find it helpful to see which HCPC codes will be considered patient facing across specialties. To access the list, scroll to the bottom of the page and click on the link titled "Quality Measure Encounter Codes."

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