Academy Comments to CMS re: Patient Relationship Categories

August 15, 2016

Andrew M. Slavitt
Acting Administrator
Centers for Medicare and Medicaid Services
Department of Health and Human Services
Attn: CMS-5517-P
P.O. Box 8013
Baltimore, MD 21244-8013

Re: Patient Relationship Categories and Codes

Dear Acting Administrator Slavitt:

The Academy of Nutrition and Dietetics (the "Academy") is pleased to provide comments to the Centers for Medicare and Medicaid Services (CMS) regarding the Patient Relationship Categories and Codes, as required by Section 101(f) of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Representing more than 100,000 registered dietitian nutritionists (RDNs)1, nutrition and dietetic technicians, registered (NDTRs), and advanced-degree nutritionists, the Academy is the largest association of food and nutrition professionals in the United States and is committed to improving the nation’s health through food and nutrition across the lifecycle. Every day we work with Americans in all walks of life — from prenatal care through end of life care — providing nutrition care services and conducting nutrition research. RDNs independently provide professional services such as medical nutrition therapy (MNT)2 under Medicare Part B.

Provided are some general recommendations related to the proposed patient categories, recommendations to modify the categories, and responses to some of the questions for consideration. It is our hope that implementation of any patient relationship categories eventually created will facilitate and support significant improvements in the scope and delivery of services for Medicare beneficiaries, ultimately improving the health and well-being of the American public.

General Recommendations

If the intent of the proposed patient relationship categories is to evaluate, attribute, and subsequently improve resource utilization within episodes of care and patient conditions, the Academy strongly recommends the patient relationship categories capture both of the following:

The nature of the patient relationships that both RDNs and other qualified healthcare professionals form when providing care that is integral, or in some instances, the primary treatment for certain episodes or conditions, even though non-physician healthcare professionals are not typically considered "accountable" providers in the context of proposed Alternative Payment Models (APMs). Based on 2014 data, "other professionals" (meaning not an MD, DO, NP, CNS, PA, or CRNA) represent a large and growing proportion of Eligible Professionals (EPs) for the Physician Quality Reporting System, increasing from approximately 17% in 2013 to nearly 24% in 2014.3 These "other healthcare professionals" – many of who are independently reimbursable providers - render critical services to Medicare beneficiaries that improve health outcomes, enhance patient satisfaction, and control spending.

And,

The clinician-patient relationships of all Medicare providers when care is provided for conditions and/or episodes as part of a health care team, regardless of the place of service, whether or not the service delivered is a covered benefit under Medicare, and regardless of whether claims are submitted for individual services or delivered as part of bundled or population-based payments in Alternative Payment Models (APMs). This could be possible through the submission of encounter data indicating that care was provided, even in instances where the service is not an independently reimbursable service under Medicare. This requirement would enable CMS to better understand both quantitative and qualitative differences in both patient outcomes and the total cost of care for various conditions and episodes. For example, data show that MNT provided by an RDN is linked to improved clinical outcomes and reduced costs related to physician time, medication use and hospital admissions for people with obesity, diabetes, and disorders of lipid metabolism, as well as other chronic diseases.4 RDNs are indeed part of the healthcare team in the delivery of these other Medicare benefits:

Medicare Intensive Behavioral Therapy for Obesity (IBT)

Auxiliary personnel can furnish this benefit under the conditions specified in regulations at 42 CFR Section 410.26(b).5 This is particularly important because studies have shown that primary care practitioners are limited in time, training, and skills to conduct the most effective, high-intensity interventions. In fact, the Institute of Medicine in 2000 "rate[d] dietary counseling performed by a trained educator such as a [registered] dietitian as more effective than by a primary care clinician."6 RDNs are not recognized as eligible billing providers for IBT, however, CMS would benefit from the ability to evaluate the patient relationship in this context, the effectiveness of the care, and to incentivize the delivery of care by the most cost-effective providers.

Medicare Diabetes Self-Management Training (DSMT)

The 2012 National Standards of Diabetes Self-Management Education and Support require at least one of the instructors responsible for designing and planning Diabetes Self-Management Education (DSME) and Diabetes Self-Management Support (DSMS) will be a registered nurse, registered dietitian, or pharmacist with training and experience pertinent to DSME, or another professional with certification in diabetes care and education, such as a CDE or BC-ADM.7 Proof of meeting the national standard is required for American Association of Diabetes Educators accreditation and American Diabetes Association recognition, one of which is required for reimbursement by CMS for DSMT services.8

Medicare Annual Wellness Visit

Registered dietitians are identified as one of the types of health care providers who can furnish this benefit.9

Medical Nutrition Therapy

Medicare only covers outpatient MNT services provided by RDNs for beneficiaries with diabetes, non-end stage renal disease (non-dialysis) or post kidney transplant.10 The care provided as part of an episode or condition, and by extension, the patient relationship of the RDN as part of interdisciplinary teams in both the inpatient and numerous post-acute and ambulatory settings, will only be visible to CMS and the Secretary of Health and Human Services if the patient relationships of all other professionals involved in the care are reported in claims and/or as encounters. Reporting of patient relationships should be possible with encounter data indicating that care was provided, even in instances where the service is not an independently reimbursable service under Medicare. For example, MNT provided for a patient undergoing chemotherapy to prevent interruptions in treatment, avoidable emergency room admissions or unplanned hospitalizations due to nausea, malnutrition, vomiting, diarrhea or other complications is not a covered benefit. CMS would benefit from the ability to evaluate the impact of this care on resource utilization. Understanding the patient relationships of other health care providers is essential to CMS's ability to understand the "secret sauce" (e.g., providers and services) that improves patient care.

The Academy also asks that consideration be given to the administrative burden that will be placed on all providers as patient relationship categories are implemented. We encourage CMS to implement these categories in a way that minimizes the administrative burdens of providers and their staff.

Recommendations for Patient Relationship Categories

The Academy has the following recommendations to modify the category descriptions to more accurately describe the patient relationships and responsibilities of other professionals, improve provider self-identification of the appropriate patient relationship at the time of care, and to improve robustness of the data for evaluation of resource use in clinical episodes and for conditions.

Recommendations for Continuing Care Relationships:

1. Add the term "preventive care" to the first category to recognize the full scope of the clinician-patient relationship in primary care.

"Clinician who is the primary health care provider responsible for providing or coordinating ongoing care of the patient for preventive, chronic and acute care."

If the intent is to recognize specialists who may be in the role of managing the totality of care for patient, CMS could consider modifying the language to "primary provider of health care" rather than primary health care provider.

2. Clarify whether the second category, "clinician who provides continuing specialized chronic care to the patient," includes other qualified health care professionals (e.g., registered dietitian nutritionists, occupational therapists, physical therapists, speech therapists, social workers). If the intent is to include other qualified health care professionals in addition to specialist physicians, then the examples should be expanded to reflect the inclusion of non-physician providers, such as a registered dietitian nutritionist providing ongoing MNT for a patient with diabetes, chronic kidney disease (CKD), irritable bowel disease and other gastrointestinal conditions, HIV, hypertension, celiac disease, congestive heart failure, cardiovascular disease, malnutrition, eating disorder, obesity, hepatic disease, Chronic Obstructive Pulmonary Disease, or cancer.

Alternatively, CMS could consider using a different term that is more inclusive of non-physician providers. Replacing the word "specialized" with the word "focused" would embrace a larger subset of providers in addition to board certified specialist physicians.

"Clinician who provides care that is continuous and focused for a chronic condition(s)"

Examples include but are not limited to: any specialist physician providing ongoing treatment for a condition or episode, physical therapist or occupational therapist providing rehabilitative services following surgery or injury, speech therapist providing care following stroke, registered dietitian nutritionist providing ongoing MNT for chronic condition (see examples above in 2), social worker coordinating care for patient with dementia.

3. The Academy recommends that CMS create a third category of continuing care relationships for non-physician providers that describes the relationships of providers whose care is integral to the management of episodes or conditions. Creation of a third relationship category serves the purpose of enabling CMS to better distinguish the care and evaluate resource utilization of focused services provided by other qualified health care professionals that are part of the treatment and management of conditions, yet separate and unique from treatment provided by specialist physicians. The care provided by many other qualified health professionals is not universally captured or consistently identifiable in claims data, and thus, the reporting of these patient relationships regardless of coverage or payment for each individual service is important. As an example, and stated previously, Medicare Part B coverage for MNT is limited to diabetes, CKD and post-kidney transplant. Much of the care provided by RDNs (i.e., resource use) in numerous health care settings and for other conditions are currently "invisible" to CMS (e.g., MNT for cancer diagnoses). CMS's ability to identify and describe high value care and ideal resource utilization can only be accomplished with the ability to take a closer look at the totality of care provided and both the patient and the team inter-relationships. Here is an example of language that would better capture the clinician-patient relationship of other health professionals:

"Non-physician clinician who provides care that is integral to preventive, chronic and acute care."

Examples include but are not limited to those services described for other professionals in category ii, and should also include services that are not currently paid for under Medicare fee-for-service but may be delivered as part of CMS Innovation Center Models or Alternative Payment Models. Additional examples include RDNs who provide care along a prevention-wellness continuum, MNT for diabetes prevention, RDN role in cardiac rehabilitation program, dietary management of acute or chronic pancreatitis, eating disorders, gastroparesis, renal insufficiency, celiac, pre-operative and long term post-operative nutritional management for surgical intervention for obesity, pre-transplant (kidney, liver) to post- transplant nutrition management, screening and MNT for nutritional deficiencies in older adults.

Recommendations for Acute Care Relationships:

The Academy recommends that the acute clinician-patient relationships of all health professionals involved in the care for episodes and conditions be reported, even if the provider's services are not eligible for reimbursement under Medicare Part A, which includes services provided by RDNs in the inpatient setting. As stated previously, appropriate resource use can only be elucidated if CMS is able to evaluate the full scope of resources – i.e., all of the providers and services - involved in care. The Academy has the following recommendations intended to strengthen the clinician-patient relationship categories and enable CMS to better understand both quantitative and qualitative resource use in acute care.

CMS may want to provide a definition of consultation for the purposes of the clinician patient relationship categories, as the term may has different meanings to different providers and in different settings. If CMS's definition of "consultant" in the context of the clinician- patient relationships is more broadly defined than by the Department of Health and Human Services Office of Inspector General11 and encompasses ongoing evaluation and management in an acute patient relationship, then the proposed clinician-patient relationship category will work for other healthcare professionals including RDNs. However, if the definition of "consultant" is more narrowly defined, and does not allow for the provision of ongoing evaluation and management then there may be a need to either broaden the definition for this purpose, or to create an additional category for other healthcare professional providing team-based care per protocol. For example, the role and responsibility of RDNs in the inpatient setting may include approval of nutritional supplements, nutritional assessments, dietary counseling, and evaluation of patients' tolerances for diets, plan and implementation of care to meet the nutritional needs, and maintain pertinent patient data to meet patients' nutritional needs; therefore has a broader responsibility than a consultant.

The Academy recommends:

1. If the definition of consultation is limited and does not include ongoing evaluation and management, an additional patient relationship category be created to describe the relationship of other providers who are not the "responsible provider," not a "consultant," and not a "non-facing clinician." Here is an example of language to distinguish between more narrowly defined “consultants” and other health care professionals who may provide consultative, yet ongoing evaluation and management during a course of care:

"Clinician who furnishes health care services or provides ongoing care during an acute episode, yet is not the responsible provider"

Examples include but are not limited to: RDN assessment and intervention for acute kidney injury; RDN and pharmacist providing ongoing management and education for acute exacerbation of Congestive Heart Failure; RDN on transplant team providing ongoing nutritional management within an episode; RDN assessment and ongoing nutritional management for renal complications (pre-dialysis); RDN ongoing monitoring and adjustment for enteral or parenteral nutrition; intervention, monitoring of malnutrition during an acute episode; RDN providing nutrition assessment and intervention for a patient with non-healing pressure wound; nutritional management of patient with head and neck cancers throughout acute course of care.

2. The creation of an additional category to capture the clinician-patient relationship of the clinician who provides services during care transitions, since the proposed patient relationship categories do not describe the relationship of a clinician working in a rehabilitation facility, skilled nursing facility, or home health agency who is not the primary provider of care, the provider of specialized chronic care, the provider responsible for an acute episode, or a consultant, based on the examples provided with the proposed categories.

"Transitional Care is a broad range of time-limited services designed to ensure health care continuity, avoid preventable poor outcomes among at-risk populations, and promote the safe and timely transfer of patients from one level of care to another or from one type of setting to another. Transitional care is complementary to but not the same as primary care, care coordination, discharge planning, disease management or case management. The hallmarks of transitional care are the focus on highly vulnerable, chronically ill patients throughout critical transitions in health and health care, the time-limited nature of services, and the emphasis on educating patients and family caregivers to address root causes of poor outcomes and avoid preventable rehospitalizations."12 Clinician-patient relationships in transitional care are pivotal to influencing patient outcomes and spending, and should be reported and evaluated. If CMS is able to provide parameters as to when an acute patient relationship becomes a continuing care relationship, this recommendation may not be necessary. In the event that CMS does not provide clearer distinctions between acute and chronic, then there may be considerable value in identifying providers whose clinician-patient relationships are "transitional," yet neither "acute" nor "chronic." The following language may bridge the categories between acute and continuing care:

"Clinician who provides transitional care to the patient where the clinician is not the primary provider of care, not providing specialized ongoing care, and not acting as a consultant."

Examples include but are not limited to: an RDN providing MNT and lifestyle education as part of a cardiac rehabilitation program, physician providing care in a skilled nursing or rehabilitation facility; home health clinicians providing transitional care services such as education by an RDN for managing tube feedings or insulin pump training at home; an RDN providing MNT that is temporary yet it is not an acute care relationship, not a consultative or ongoing care relationship; an occupational therapist providing services in the home following an acute episode of care, until the patient is able to receive ongoing outpatient treatment.

This category could include both physicians and non-physician providers, and should capture the clinician-patient relationships independent of CPT or HCPCS codes or whether the services provided are payable under Medicare Part A or Part B. If CMS intends to identify and define what "high value care" looks like, it is important to capture the patient relationships of all providers involved in care.

In response to CMS's request for comment on the questions in bold, please find the Academy's response below:

CMS Question #1: Are the draft categories clear enough to enable physicians and practitioners to consistently and reliably self-identify an appropriate patient relationship category for a given clinical situation? As clinicians furnishing care to Medicare beneficiaries practice in a wide variety of care settings, do the draft categories capture the majority of patient relationships for clinicians? If not, what is missing?

If CMS selects to maintain the proposed framework of acute or continuing care, versus broad or focused care, the proposed categories are not clear enough to enable physicians and practitioners to consistently and reliably self-identify an appropriate patient relationship category for a given clinical situation. There is likely to be overlap that will be difficult to distinguish. For example, an RDN working in an inpatient oncology unit has acute care relationships, but may also have patients who are admitted to the hospital and stay for long periods of time, therefore developing continuing care relationships that are wider in scope. Time frame or other qualifying criteria is necessary for clinicians to be able to determine whether the relationship is a continuing care or an acute care relationship. For example, if a patient is admitted to a rehabilitation facility for two weeks the clinician-patient relationships might be considered "acute." If a patient stays for greater than two weeks, does the relationship become a continuing care relationship, even in the acute setting? There is a need for clearer definitions and time frames. Also see recommendations for transitional care relationships above.

CMS Question #6: What type of technical assistance and education would be helpful to clinicians in applying these codes to their claims?

CMS should consider a pilot testing process for validating all the clinician-patient relationship categories for all categories of physician and non-physician Medicare providers prior to 2018. A checklist or algorithm developed from the final set of patient relationship categories would be helpful to both clinicians and administrative staff who may be responsible for submitting claims. Videos that walk providers and administrative staff through the process would also be helpful. Multiple examples using multiple settings (places of service) for both physicians and other qualified health care professionals will be necessary to help providers select the appropriate clinician patient relationships and enable CMS to accurately assess resource utilization. CMS could consider employing a support line at the beginning of 2018 and post examples of less-clear-cut scenarios online for other providers, with rationale for the selection of the clinician-patient relationship category.

Thank you for your careful consideration of the Academy's comments on these proposed rules. The Academy looks forward to continued opportunities to work with CMS to design health care delivery and payment systems that improve the health of the nation and meet the needs of all stakeholders. Please do not hesitate to contact Jeanne Blankenship by phone at 202-775-8277 ext. 1730 or by email at jblankenship@eatright.org or Marsha Schofield at 312-899-1762 or by email at mschofield@eatright.org with any questions or requests for additional information.

Jeanne Blankenship, MS, RDN
Vice President, Policy & Advocacy
Academy of Nutrition and Dietetics

Marsha Schofield, MS, RD, LD, FAND
Senior Director, Governance
Academy of Nutrition and Dietetics


1 The Academy has approved the optional use of the credential "registered dietitian nutritionist (RDN)" by "registered dietitians (RDs)" to more accurately convey who they are and what they do as the nation's food and nutrition experts. The RD and RDN credentials have identical meanings and legal trademark definitions.

2 Medical nutrition therapy (MNT) is an evidence-based application of the Nutrition Care Process. The provision of MNT (to a patient/client) may include one or more of the following: nutrition assessment/reassessment, nutrition diagnosis, nutrition intervention and nutrition monitoring and evaluation that typically results in the prevention, delay or management of diseases and/or conditions. [Academy of Nutrition and Dietetics' Definition of Terms list updated July 2016. Accessed August 8, 2016.] The Academy's definition of medical nutrition therapy is broader than the MNT definition established by Medicare Part B and other health plans. In addition, the Academy definition may differ from the MNT definition included in state licensure laws. The term MNT is sometimes used interchangeably with, but is sometimes considered different from, nutrition counseling in health insurance plans.

3 2014 Reporting Experience Including Trends (2007-2015), Physician Quality Reporting System. April 15, 2016. Centers for Medicare & Medicaid Services.

4 Academy of Nutrition and Dietetics Evidence Analysis Library. Medical Nutrition Therapy Evidence Analysis Project 20013-15. Accessed July 26, 2016

5 Intensive Behavioral Therapy (IBT) for Obesity. Accessed August 4, 2016

6 Committee on Nutrition Services for Medicare Beneficiaries, Food and Nutrition Board of the National Academy of Science, The Role of Nutrition in Maintaining Health in the Nation's Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population; 2000, p11.

7 Haas, et al "National Standards for Diabetes Self-Management Education and Support" Diabetes Care 2013 Jan; 36(Supplement 1): S100-S108. Accessed August 8, 2016.

8 CMS "Diabetes Self-Management Training and Certified Diabetes Educator" MLN Matters, MM6510 August 7, 2009. Accessed August 8, 2016.

9 Department of Health and Human Services "ABCs of the Annual Wellness Visits" Medicare Learning Network ICN 905706 January 2015. Accessed August 8.

10 Center for Medicare and Medicaid Services National Coverage Determinations Manual Chapter 1, Part 3 (Sections 170 – 190.34) Medical Nutrition Therapy (Rev. 181, 03-27-15). Accessed February 18, 2016.

11 Levinson, Daniel, Inspector General, "Office of the Health and Human Services Office of the Inspector General, Consultations in Medicare: Coding and Reimbursement" March 2006. Accessed July 27, 2016.

12 Naylor, M.D., Aiken, L.H., Kurtzman, E.T., Olds, D.M. & Hirschman, K.B. "The importance of transitional care in achieving Health Reform," Health Affairs 2011; 30(4):746-754