Primary Care Coding Alert

CMS’s new value-based payment model points to primary care future.

There’s a lot to unpack in the new Primary Cares Initiative, which was unveiled by the Centers for Medicare and Medicaid Services (CMS) in an April 22, 2019 press release.

But some things are pretty clear. First, the Initiative looks to put primary care at the heart of the American healthcare system for practical and financial reasons. Second, it marks a continuation of the movement away from the fee-for-service payment model that has been so prevalent in recent years to a more streamlined, efficient, value-based model that potentially benefits all stakeholders involved.

Here, then, are some of the Initiative’s key goals and provisions, along with some expert analysis that examines the implications for your practice and primary care providers across the nation.

What Is the CMS Primary Cares Initiative?

The Initiative’s goals are twofold. First, “it puts the primary care physician in the center of the payment model,” according Kristen M. Barlow, a consultant with Dorsey Health Strategies, a consultancy affiliated with the law firm of Dorsey & Whitney LLP in Minneapolis, Minnesota. In other words, it acknowledges that “primary care clinicians serve on the front lines of the healthcare delivery system … [and] strengthening primary care is associated with higher quality, better outcomes, and lower costs within and across major population subgroups,” according to the Primary Cares Initiative press release (Source: www.cms.gov/newsroom/press-releases/hhs-news-hhs-deliver-value-based-transformation-primary-care).

To accomplish this, the Initiative promises to “reduce administrative burdens and empower primary care providers to spend more time caring for patients while reducing overall health care costs,” the press release continues.

In addition, the Initiative is based on “population health management, the goal of which is to keep patients healthier for longer without hospitalization,” says Barlow. In turn, this reduction of “hospital utilization and total cost of care … will reduce total Medicare expenditures,” the press release goes on to note.

Who Can Participate in the Primary Care First Model of the Initiative?

The Initiative consists of five different payment models. Two of them, the Primary Care First (PCF) and the PCF — High Need Populations models, are of most interest to primary care practices as they “are focused on individual primary care practice sites,” according to CMS. However, not all primary care practices will be able to participate in PCF.

First, “to benefit from the model, your primary care practice must be in one of the 26 regions where PCF will be offered,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

Second, your practice will need to have “advanced primary care capabilities, such as 24/7 access to a practitioner or nurse call line and empanelment of patients to a practitioner or care team — and be prepared to accept increased financial risk in exchange for flexibility and potential rewards based on practice performance,” Moore explains.

“Practices that might benefit will also need to have experience with value-based payment arrangements or payments based on cost, quality, and/or utilization performance and have certain other characteristics, including at least 125 attributed Medicare beneficiaries and use of 2015 Edition Certified Electronic Health Record Technology [CEHRT],” Moore continues.

You can find a map of regions and an outline of the Initiative’s guidelines by going to innovation.cms.gov/initiatives/primary-care-first-model-options/.

How Will the PCF Payment Model Work?

The PCF payment model has some important implications that may well go beyond the Primary Cares Initiative to affect future private-payer value-based payment models.

It also contains some pretty important implications for primary care coding.

The first part of the payment model, the professional population-based payment, involves identifying the practice’s risk group based on the average hierarchical condition category (HCC) score of all attributed Medicare patients in the practice. HCC scores are driven by patients’ ICD-10 diagnoses. “CMS will make payments to a practice based on the average HCC of all their attributed Medicare patients. Once that average is determined, the practice gets a per-beneficiary, per-month payment for all attributed Medicare patients, regardless of the patient’s individual HCC. The payments will be as low as $24 for each patient in the low-risk group and as high as $175 if the average HCC score puts the practice in the high-risk group,” explains Barlow.

Coding alert 1: This means “diagnosing to the highest level of specificity and highest appropriate level of acuity will have financial implications to practices going forward, so practices will need to understand how diagnosis coding feeds into HCC scoring,” Moore points out The second part of the payment model involves “a flat, $50.52 payment for every face-to-face patient encounter, which will make it easier for practices to predict payments in the future,” continues Barlow.

Coding alert 2: The flat fee is also a further indication that CMS is looking to discontinue paying for different levels of outpatient evaluation and management (E/M) services, a move that they have strongly hinted at since before the publication of the 2019 Physician Fee Schedule Final Rule in December 2018.

The bottom line: As promising as all this sounds, “there’s still a lot that’s unknown” about the Initiative, Moore cautions. Further, “it is hard to say how it will impact other payers,” adds Barlow.

Primary Care Coding Alert will follow the Initiative closely and update you as things progress.

The first round of the Primary Cares Initiative will begin in January 2020, with a second round of applications planned for the following year. CMS will test the Initiative for five years.