Academy submits comments on episode groups to CMS

May 2016 - Vol. 35, No. 04

As part of an ongoing effort to represent Members in the quickly changing healthcare payment landscape, on March 1, 2016, the Academy submitted comments to the Centers for Medicare & Medicaid Services (CMS) on the Request for Information (RFI) on Episode Groups. Episode groups are resource-use measurement methods that consist of care episode groups, patient condition groups, as well as patient relationship categories and codes. These resource-use measurement methods will be an important component for determining appropriate payment for physicians participating in Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs).

In comments submitted to CMS, the Academy reiterated that it is essential that CMS allow for the widest range of innovative ideas to ensure the greatest numbers of physicians are able to not only participate, but succeed in future payment models. The Academy also emphasized the need for institutional flexibility in episode groups to continue to treat patients, even if the condition does not fit into a group, and CMS must not penalize physicians for providing treatment as part of a well-established pattern of care. Any episode groups developed by CMS should ensure that any quality program change comes with adequate technical support; the primary components of the proposed programs should be clearly defined; and that measure alignment should occur between MIPS and Medicare Access & CHIP Reauthorization Act of 2015 (MACRA)-defined APMs.

Members can access and read the full comment letter at

Episode Group definitions
Resource-use Measurement: One component of a practitioner’s total MIPS score based on the care episode, patient condition, and patient relationship codes that will be submitted on Medicare Part A, B, and, if determined appropriate, Part D claims.

Care Episode Groups: Groups that take into consideration a patient’s clinical problems at the time items and services are furnished during an episode of care.

Patient Condition Groups: Groups that take into consideration a patient’s clinical history at the time of a medical visit, such as the patient’s combination of chronic conditions, current health status, and recent significant history.

Patient Relationship Categories: Categories used to define and distinguish the relationship and responsibility of a physician with a patient at the time of furnishing an item or service.