In this week’s episode of Ask Dr. Mingle, Dr. Dan Mingle provides an overview of the Primary Care First program before outlining a few things that could go wrong with a PCF quality submission.

Later, Dr. Mingle shares some advice for choosing a Population Health measure when considering a MIPS Value Pathways (MVP) submission.

Click play to listen to this episode now:

Question One: Primary Care First Explained

Hadley asks: “In preparation for our first question, can you remind us what Primary Care First is?”

Primary Care First (PCF) is one of the newest additions to the experimental Alternative Payment Models under the Center for Medicare and Medicaid Innovation (CMMI). PCF replaces the Comprehensive Primary Care + (CPC+) program that ran from January 1, 2017, through December 31, 2021. CMMI integrated lessons learned from the CPC+ program into the PCF program, and CPC+ participating practices were encouraged to roll over into the PCF program.

Approximately 2600 practices are participating in 2 PCF cohorts. The first cohort started on January 1, 2021. The second cohort started a year later. The program will end after the 2026 performance year.

In PCF, practices are sorted into four strata by the average complexity score of the attributed patient panel, as indicated by average patient Hierarchical Condition Category (HCC) scores.

Payment for Primary Care First participants is a combination of the following:

• Prospective Quarterly Professional Population-based Payment – a care management fee tiered to the risk strata of the practice
• A flat visit fee for primary care visits paid based on claims
• And a Performance-based adjustment, paid quarterly

Factoring into the Quarterly Performance Based adjustment are:

• The Total Per Capita Cost measure (TPCC) calculated by Medicare from claims
• The Acute Hospital Utilization measure calculated by Medicare from claims
• And a set of quality measures

As with all Alternative Payment Models under the CMMI, quality measurement is required.

The specific measures required vary by complexity strata, as measured by the average HCC risk score of the patient panel.

Measures for the two lower-risk strata (Levels One and Two) are:

• Measure #1 – HbA1c
• Measure #236 – Controlling High Blood Pressure
• Measure #113 – Colorectal Cancer Screening
• Advance Care Plan
• CAHPS survey

And measures for the two higher-risk strata (Levels Three and Four) are:

• Advance Care Plan
• CAHPS Survey
• Days at Home measure (suspended starting in the 2023 performance year)

Question Two: Primary Care First Quality Submission Disqualified

Miranda asks: “We are participating in Medicare’s Primary Care First program. We submitted our quality measures for 2022 as eCQMs. Our quality submission was disqualified. Why did that happen? What can we do about it?”

Not knowing the specifics of your situation, several things can go wrong with your quality submission.

I’ll outline what can go wrong by working backward from a winning score.

The first potential problem is the score.

Quality measures have a pass/fail dynamic for Primary Care First. You must have a score that meets or exceeds the 30th percentile on each quality measure to earn any of your quarterly performance-based adjustment. Medicare publishes the goal benchmark minimum performance rate for each measure annually, early in the performance year.

The second potential problem is the timeliness of the submission.

For the HbA1c, blood pressure control, and colorectal cancer screening measures that apply to risk strata one and two, those measures must be submitted to Medicare before the close of the annual submission window, typically at the end of the day on March 31.

The third problem is the mechanism.

Primary Care First is one of the few programs that limits choice. Each measure has to be submitted using the proper means by the March 31 due date. In most programs, practices can submit the HbA1c, blood pressure control, colorectal cancer screening measures, and advance care plan measures by eCQMs, MIPS CQMs, or claims. For PCF, the HbA1c, blood pressure control, and colorectal cancer screening measures must be submitted as eCQMs. Medicare calculates Advance Care Plan from your part B claims as an Administrative Claims measure.

The fourth potential problem is EHR documentation workflows.

For the eCQM measures, you must have entered data for each patient in the right place to be picked up by the eCQMs. You might have performed the care, and you might have recorded it in the chart. But if the record is not visible exactly how and where the eCQM tool is looking for it, you may fail to achieve a winning benchmark.

The fifth potential problem is Advance Care Planning documentation workflows.

Your most significant risk is probably the Advance Care Plan Administrative Claims measure. Medicare will look in your claims for CPT billing codes 99497 or 99498, indicating a charge for a visit in which you discussed an Advance Care Plan. They also look for the CPT II QDC codes 1123F or 1124F, indicating you did it previously or did it in this visit in a context that you could not or did not bill specifically for. You might have done it, and it might be clearly recorded in the chart. But if it was not reflected in a claim with one of these service codes attached to a visit in the applicable performance year, it will not be credited to you.

So you have failed and are destined not to collect a performance-based adjustment this year. What can you do?

Two things to consider:

• First, fix whatever went wrong for the current performance year:
  • Ensure you’re recording data in the right place for the EHR to pick it up for the eCQM measures. That’s HbA1c, blood pressure, and colorectal cancer screening.
    • Put it in the right place on all of your visits in the future. You can also amend your prior visits to transcribe the collected data in the right place to be collected.
  • If you have not been adding an Advance Care Plan code to your Medicare claims, you only have to do it once a year for each of your eligible patients.
    • Eligible patients are Medicare patients 65 or over. Do it on the next visit if you will see them again.
    • You are not permitted to amend a previous claim with a CPT II QDC code, but if you missed an opportunity to bill for the Advance Care Plan discussion, you could submit an amended claim including that code.
• Second: You can request a targeted review by Medicare.
  • To request a targeted review, log in using our HARP credentials at qpp.cms.gov and choose “Targeted Review” from the menu on the left.
    • You will see a list of permissible and impermissible reasons for review in the application form.
    • If your request is not permitted, you can enter a ticket to request help from the QPP help desk.

Question Three: Choosing a Population Health Measure for an MVP

June asks: “We are considering participating in MIPS Value Pathways for 2023. How do I know which Population Health measure to choose? Should I choose one that we won’t have eligibility for, so it gets reweighted?”

That is an interesting thought, but unfortunately, it won’t work that way.

When you participate in an MVP, you have to choose one of the two Population Health measures which are available to all MVPS:

• Measure #479: Hospital-Wide, 30-day, All-Cause Unplanned Readmission (HWR) Rate
• Measure #484: Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions

Both are Administrative Claims measures, which means Medicare calculates the results from claims submitted for care.

Though it might change in the future, Medicare calculates Administrative Claims measures at the Tax ID-specific whole practice level. They will not be calculated at the subgroup level.

You can choose whichever measure, and CMS will calculate the measure if you meet case minimums. If you don’t meet case minimums, they’ll attempt to calculate the other measure you did not select.

If one or both are measurable, that score will be integrated into your quality score.

The Population Health selection will not factor into your quality score if you don’t meet case minimums on either measure. You won’t have Population Health achievement points in your quality numerator, and the ten potential achievement points for Population Health will not be reflected in the quality denominator.

Send us your value-based care questions!

If you’d like to ask a question about the APP transition, MIPS, Primary Care First, ACO quality reporting, or any other Alternative Payment Model, you can reach out to us in three ways:

You can leave your questions in a YouTube comment under any episode of Ask Dr. Mingle.

On LinkedIn, leave your questions in a comment on any of our posts.

And you can reach out directly by sending an email to hello@minglehealth.com.

Want to learn more about the MIPS program in 2023?

As MIPS becomes more difficult, it's crucial to have a plan in place. We've made a guide that provides an overview of 2023 MIPS requirements and changes to help you and your organization find success in the 2023 Performance Year.

Access the Guide