The ACC commends CMS' efforts to remove obstacles to care and support professional well-being through its "Patients Over Paperwork" initiative. However, the College fears the current slate of proposals would have unintended negative repercussions. Therefore, the ACC urges CMS not to finalize this package of proposals in its entirety for implementation on Jan. 1, 2019. Instead, the ACC urges CMS to finalize the following documentation proposals while engaging with the medical community to work through the complicated and granular issues regarding accurate documentation, coding and payment for different levels of E/M visits.

• Allowing clinicians to document the level of E/M service using medical decision-making or time, eliminating the need to achieve certain points by adding a review of symptoms, complete history and physical exam–in addition to the 1995 or 1997 E/M documentation guidelines
• Eliminating the requirement for clinicians to re-document information in the medical record previously entered by ancillary staff or the beneficiary;
• Accepting documentation of the changes in the interval between visits as an alternative to "history of present illness" or "current symptoms;"
• Eliminating the prohibition that practitioners of the same group and specialty cannot bill for E/M visits on the same day;
• Eliminating duplicative requirements for notations in the medical record by teaching physicians for E/M services;
• Eliminating the requirement for additional justification for provision of a home visit rather than an office visit.

CMS proposes to implement a single payment amount for new patients at a level between the current payments for 99203 and 99204, and a single payment for existing patients between the amounts for 99213 and 99214. However, believing that payment amount to be inadequate for clinicians who commonly bill higher levels of E/M services due to the complexity of primary or specialty services, CMS proposed additional add-on codes for primary care-type services and specialty-care type services. To further allow clinicians to capture the work of complex patients, CMS proposed another add-on code for 30 minutes of prolonged services.

• It is unclear to the ACC why documentation proposals are intrinsically linked to the payment proposals. The College has significant concerns with implementing such a dramatic change to the structure of E/M coding and payment on this timeline. Because of these unsettled issues, the College again urges CMS not to finalize any E/M payment changes in 2019 and instead collaborate with the medical community to work through the complicated issues regarding accurate documentation, coding and payment for different levels of E/M visits. Of particular value to this enterprise will be the American Medical Association's (AMA) Joint Current Procedural Terminology/Relative Value Scale Update Committee Workgroup formed to further the administrative burden reduction goals of the proposals. CMS' engagement in that process will be important for developing meaningful solutions.

CMS proposed "an E/M multiple procedure payment adjustment to account for duplicative resource costs when E/M visits and procedures with global periods are furnished together," that would reduce the payment by 50 percent for the least expensive procedure or visit that the same physician (or a physician in the same group practice) furnishes on the same day as a separately identifiable E/M visit, currently identified on the claim by appending modifier 25. The ACC disagrees with this premise and urges CMS not to finalize its E/M multiple procedure payment reduction proposal for several reasons.

• Low-Volume Threshold
  The ACC supports the continuation of the low-volume threshold exempting clinicians from Merit-Based Incentive Payment System (MIPS) participation if they treat a small number of Medicare beneficiaries or provide a small number of covered services under Part B. The College agrees that this will appropriately decrease the reporting burden for clinicians who treat few Medicare beneficiaries, especially small practices and solo practitioners. However, the College encourages CMS to ensure that the low-volume threshold is not overly broad. Additionally, the ACC supports the proposal to implement an opt-in policy for those clinicians and groups that exceed one, but not all three, of the low-volume threshold criteria proposed.
• Group Reporting
  The ACC appreciates that CMS continues to explore MIPS reporting as a subgroup rather than limiting group reporting at the Taxpayer Identification Number (TIN) level only.
• Virtual Groups
  The College supports the proposal to provide interested participants with greater access to real-time TIN size information for determining whether their group meets the 10 or fewer eligible clinician threshold for virtual group eligibility.
• MIPS Performance Period
  The ACC supports CMS' proposal to maintain the performance periods for the Promoting Interoperability and Improvement Activities categories at a minimum of a continuous 90-day period within 2019. Maintaining the 90-day minimum reporting period maintains stability from previous years. Additionally, while the College encourages a 12-month reporting period in the Quality category and recommends that all participants to strive to meet a full year of quality measure reporting, CMS must recognize that this threshold may not be attainable for all clinicians. Therefore, the College recommends a 90-day minimum for the Quality category.

• Topped Out Measures
  The College continues to oppose the removal of topped out measures from MIPS. Many topped out measures promote evidence-based best practices in patient care; clinicians and groups should be recognized for maintaining these practices. Furthermore, removal of these measures would be misaligned with CMS' goal of implementing more outcome measures, as it would be impossible to develop robust outcome measures without an understanding of the processes that contribute to the outcome.
• Removal of Process Measures
  The ACC recognizes CMS' desire to move toward outcome measures; however, the College reminds CMS that many process measures are still important to maintaining patient care. CMS should proceed cautiously with the elimination of process measures and consult with measure stewards on the best approach to transitioning to outcome measures.

• Cost Category Weight
  The ACC recommends keeping the weight of the Cost category at 10 percent for Year 3 of the program. Regarding the category weight in future years, the ACC supports a gradual approach to increase the weight of the Cost performance category each year until CMS reaches the statutorily required 30 percent weight for this category for the 2024 MIPS payment year.
• Episode-Based Measures Proposed for the 2019 and Future Performance Periods
  The ACC supports the efforts of the multi-stakeholder clinician workgroups convened by CMS and Acumen to develop episode-based cost measures for the MIPS program. The ACC encourages CMS to further monitor the reliability of the Elective Outpatient PCI and Intracranial Hemorrhage or Cerebral Infarction measures to determine if similar updates to the case minimums may contribute to improving the reliability of these measures.
• Performance Period
  The ACC supports further consideration into whether the Cost category should be measured based on a two-year performance period rather than the current one-year performance period.

The ACC supports CMS' proposal to assign all Improvement Activities using certified electronic health record technology (CEHRT) as high-weight Improvement Activities, particularly in light of the proposal to eliminate the Promoting Interoperability bonus awarded for participating in an Improvement Activity using CEHRT. CMS should seek further ways to incentivize clinicians for their use of CEHRT.

By acknowledging the shortcomings of previous efforts to encourage EHR adoption through prescriptive rulemaking, CMS is making significant strides towards achieving true interoperability. ACC applauds CMS for its work with the Office of the National Coordinator for Health IT (ONC) aligning reporting requirements across care settings, eliminating redundancies and streamlining objectives and measures regardless of the program in which a clinician participates. While heartened by the steps taken in the proposed rule, the ACC encourages CMS to use the Promoting Interoperability (PI) program to promote the appropriate, purposeful and accurate use of health IT solutions, rather than mandate completion of tasks.

• Certification Requirements Beginning in 2019
  The required capabilities required in 2015 edition CEHRT, such as application programing interface (API) functionality and US Core Data for Interoperability (USCDI) through common clinical data set (C-CDS), will encourage continued progress on interoperability. While the ACC encourages continued progress towards the adoption of 2015 edition CEHRT, it is important that CMS continue to retain all current hardship exceptions for practices that are unable to meet PI criteria. The ACC also encourages CMS to continue to educate and provide resources on 2015 CEHRT criteria as clinician's transition from 2014 to 2015 edition CEHRT.
• Reporting Period
  CMS proposes continuing the minimum continuous 90-day reporting period for 2019 and 2020. The ACC thanks CMS for continuing the 90-day reporting period for 2019 and 2020 and further aligning the promoting interoperability 19 programs in the inpatient and outpatient settings by setting identical reporting periods.
• Objectives and Measures
  The College urges CMS to focus the PI program on a limited handful of high value initiatives that aim to increase the usability of EHR systems, promote clinical data standards, and reduce the amount of necessary manual tasks such as patient matching or data abstraction.

• Small Practice Scoring
  The ACC supports the continuation of small practice bonuses and flexibility for solo practitioners and groups of 15 or fewer eligible clinicians.

• Proposed Update to the Definition of a QCDR
  The ACC strongly supports CMS' proposal to modify the definition of a QCDR to state that the approved entity must have clinical expertise and quality measure development, with additional recommendations. The College presents two options for CMS' consideration. The first option would be for CMS to adopt the definition of a "clinician-led clinical data registry" in the 21st Century Cures Act. At a minimum, the second option would be for CMS to update the proposed definition to refer to entities "with clinical expertise in medicine, guideline development, and quality measurement."
• Public Reporting on Physician Compare
  Public reporting performance data through Physician Compare can better inform beneficiaries assuming the data is accurate and actionable. The ACC supports proposals not to publicly report first-year data on quality and cost measures to allow clinicians and groups to get feedback on these measures before they are publicly reported.

The ACC acknowledges CMS' interest in moving toward Advanced APMs that encourage clinicians to coordinate care for a population under a two-sided risk model. The College is encouraged by the Bundled Payments for Care Improvement Advanced model that will provide opportunities for cardiologists and other specialist clinicians to participate in an Advanced APM. CMS should continue to develop Advanced APMs that provide opportunities for specialist clinicians to meaningfully participate. Additionally, ACC reiterates the request that CMS work with Congress to reduce the payment and patient thresholds for Qualified Provider determination per the MACRA statute.

• Other Payer Advanced APM Option
  The College recommends that CMS take a cautious approach to operationalizing the first performance period where this option is available to clinicians. The ACC continues to have concerns that this will limit the ability to provide clinicians with accurate notice of their QP status unless CMS is able to coordinate this information across payers in a timely manner. CMS is proposing to streamline the process for multi-year arrangements so that the payer and/or clinician will provide information on the length of the agreement, and if there were no changes to the payment arrangement, the payer and/or eligible clinician would not have to annually attest there were no changes to the payment arrangement. The ACC supports this added flexibility and believes the ability to submit documentation only once will increase uptake of the Other Payer option. CMS is proposing to allow for QP determinations under the All-Payer Option to be requested at the TIN level in addition to the APM Entity and individual eligible clinician levels. The ACC strongly supports this added flexibility in measuring risk for purposes of QP determination.
• Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) Demonstration
  The ACC is encouraged by CMS announcing the MAQI Demonstration. The College believes it is important for clinicians in high Medicare Advantage (MA) penetration areas to receive credit for their participation in payment arrangements with similar requirements as Advanced APMs.
• MIPS Exemption Waivers
  The ACC strongly supports an exemption from MIPS for clinicians participating in qualifying payment arrangements.
• Additional Incentives for Participation in Qualifying Payment Arrangements
  The ACC strongly encourages CMS to consider the addition of a bonus payment similar to that provided for Advanced APM participation.

The ACC supports CMS' proposal to allow clinical staff working under the direction of the ordering professional to perform the consultation with AUC through a qualified CDSM, subject to applicable state licensure and scope of practice law. This approach recognizes the importance of team-based care, lessens the burden on ordering professionals, and should not diminish the ordering professional's interest and engagement in AUC, as all services ordered under their NPI will count toward determining outlier status.

As with any new requirement, CMS must educate clinicians and their staff early on how to use new codes. The ACC recommends that CMS begin education in 2019, so clinicians can take full advantage of the 2020 educational year to begin submitting claims using the new codes. At the end of 2020, CMS should provide clinicians with reports stating whether they have been properly documenting AUC consultation on their claims submissions, as well as preliminary data on their adherence patterns to allow them to prepare for data collection in 2021.

The College supports the implementation of a significant hardship exemption for clinicians who may have insufficient internet access, EHR or CDSM vendor issues, extreme and uncontrollable circumstances, lack of control over the availability of CEHRT, have been practicing for less than 2 years, and/or lack face-to-face patient interaction.

Developing a valid and fair methodology requires a thorough consideration of how AUC are designed, the patient factors that may impact a clinician's ordering patterns and an understanding of other variables that may impact CMS' ability to identify true outliers. CMS must ensure that the methodology does not unintentionally result in the underutilization of advanced imaging services to Medicare beneficiaries.

• As part of its annual review, CMS should determine an appropriate threshold for outlier identification. If there is no statistically significant difference among ordering patterns within a given year, CMS should lower the number of outlier professionals identified or even determine that no outliers can be identified.
• CMS should ensure that the methodology is fair, regardless of what provider-led entity (PLE) developed the AUC a clinician chooses to use. PLEs utilize thorough, systematic review processes when developing AUC ratings; however, CMS must remember that the rating outcome may vary depending on a panel's assessment of available evidence. CMS should consider how this potential variability among AUC for a given condition or modality may impact the outlier methodology.
• CMS should explore whether additional factors, not readily available through claims data, impact the outlier methodology. For example, differences in ordering patterns by geographic regions, ethnic groupings, practice settings or complexity of patients.
• CMS must remember that AUC documents do not cover all possible clinical scenarios. While rare, patients falling outside of the clinical scenarios covered by AUC should be excluded from the outlier calculation based on the reasonable medical judgment of the ordering professional.
• CMS should be aware of current CDSM capabilities when developing outlier methodology. Some CDSMs make it nearly impossible to complete an order for tests with "rarely appropriate" or "not adherent" ratings, complicating CMS' calculations of valid outliers, as few clinicians should be reporting non-adherence to AUC on the final claim.