In this week’s episode, Dr. Dan Mingle answers questions from Michael, Arnaud, and Tom. First, Michael asks for clarification on mixing MIPS CQMS and eCQMs in a quality submission. Next, Arnaud asks Dr. Mingle about payment for non-primary care services in Primary Care First (PCF). And later, Tom asks Dr. Mingle for his opinion on how to handle an unconventional provider type in an ACO.

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Question One: Mixing MIPS CQMS and eCQMs in a Quality Submission

Michael asks: “I understand the difference between the MIPS Clinical Quality Measures (MIPS CQMs) and Electronic Clinical Quality Measures (eCQMs), but I am struggling to understand reporting requirements. Are you not able to have a mix of the two in your Quality submission? I am reading that you have to choose one or the other, but if that is true, does that mean that certain measures in the same specialty set can’t be submitted together – like #155 and #318 under Podiatry?”

Most people do make it a choice between eCQMs and MIPS CQMs. But the truth is, you can mix and match mechanisms.

It’s helpful to include a quick review of quality measure mechanisms under Medicare’s Quality Payment Program here before we continue.

MIPS Clinical Quality Measures (MIPS CQMs):

MIPS CQMs are submitted to Medicare by a Qualified Registry. Qualified registries have complete freedom to retrieve data anywhere it exists, even combining data sources, to create what is generally the most accurate analysis. Your organization could qualify as a registry if you wanted to, or you can work with a third party like Mingle Health.

Electronic Clinical Quality Measures (eCQMs):

eCQMs are typically generated by Electronic Health Record (EHR) software. Some third-party vendors also create and submit eCQMs. Every step in the eCQM chain of data storage, data recovery, and analysis has to be certified by standards set by the office of the National Coordinator of Healthcare Information Technology (ONC).

QDC Codes:

Medicare Part B Claims measures involve adding a Quality Data Code (QDC) Code to patient claims sent to Medicare. This mechanism has typically been the least reliable, and it is today permitted for use only by small practices.

Qualified Clinical Data Registry (QCDR) Measures:

QCDR measures are generally built, tested, and maintained by a third party and approved annually by Medicare. These are typically topics specific to the third party and are often specialty-specific. Many specialty societies operate QCDRs.

When completing quality submissions, any practice can submit the following:

• Duplicate measures
• More measures than needed
• Measures from multiple mechanisms
• And measures from multiple vendor sources

Whether the scores come from one or multiple mechanisms or vendors, Medicare follows the following three rules:

1. If a measure is submitted in duplicate from the same vendor using the same mechanism, the most recent submission overwrites prior submissions.
2. When multiple vendors submit, or multiple mechanisms are used to submit duplicate measures, Medicare grants the best score received.
3. If excess measures are submitted, Medicare counts the six highest-scoring measures.

Question Two: Primary Care First & Billing for Non-Primary Care

Arnaud asks: “Thanks a lot for your great summary video of PCF. I have one question though: is billing and payment for non-primary care affected? For example, would radiology services still be paid under traditional Fee-For-Service (FFS)? If so, are there any FFS payment adjustments linked to quality performance measures? Thank you.”

There are three buckets of payment in the Primary Care First Program:

1. There’s a monthly prospective care management fee for attributed patients.
2. There’s a flat visit fee for all visits utilizing codes that Medicare considers Primary Care Codes. Medicare annually updates and publishes this list.
3. And there’s Fee-For-Service for any services that are not in the list of Primary Care Codes. Payment is made consistent with the annually updated physician fee schedule.

CMS applies any Quality adjustments earned to the monthly prospective payment and the flat visit fee. These adjustments do not affect charges for non-primary care services.

Question Three: EUC Application for a Unique Practice in an ACO

Tom asks: “We have a physician in our ACO who only provides telephonic on-demand services. He is referred patients from a clinically-oriented website and provides telephonic services, mainly for urgent care type problems.

He bills telehealth codes 99441, 99442, and 99443.

Based on his exclusive use of the 99441, 99442, and 99443 CPT codes, he has no liability for 2 of the three APM Performance Pathway quality measures: HgbA1c Control and Blood Pressure Control.

But his billing codes are included in the eligible codes for the depression screening and management measure, number 134.

As you can imagine, patients calling in for an acute or chronic arthritic complaint may not be in the right mindset to answer questions about their mood while experiencing pain. It also would not be appropriate for this doctor after interacting with the patient a single time, to recommend a treatment plan, especially since he has no means to follow up with these patients or familiarity with the available resources in their area.

We would like to know if an Extreme and Unusual Circumstances (EUC) application is applicable. Do you have any advice?”

An interesting practice filling a useful niche!

But, I wonder if it is a practice you want to maintain in your ACO. Does it provide enough value to ACO-attributed patients to be worth your administrative time and the risk to your ACO quality scores?

You are correct about the diabetes and hypertension control measures in the APP measure set. The three codes your doctor bills are not in the measure specifications, so your doctor will have no eligible instances for either measure 1 or 236.

But 99441, 99442, and 99443 are in the specifications for the depression screening measure – number 134. So, all of this physician’s patients will be eligible for that measure.

You can try an EUC. Our staff provides assistance and/or guidance to our clients with EUC applications. I’m a little doubtful that Medicare will reliably, year after year, approve that application, though.

The “my patients are too focused on their pain to be willing to answer questions about depression” argument could apply to most provider-patient interactions.

I’m inclined to think that patients in this setting might be at particularly high risk for depression. Patients who are avoiding in-person evaluation are at risk of having their signs and symptoms of depression missed. It may be especially valuable to include a simple screening in these encounters.

I suggest that you include a simple screen in the pre-visit assessment. There’s excellent evidence that patients are more open to answering sensitive questions on a form than when verbally interacting with their provider.

And, management does not have to be definitive. Referral to a hot-line number or the patient’s primary care provider can suffice.

Send us your value-based care questions!

If you’d like to ask a question about the APP transition, MIPS, 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?

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