Merit-Based Incentive Payment System (MIPS): Total Per Capita

Merit-Based Incentive Payment System (MIPS):

Total Per Capita Cost (TPCC) Measure

Measure Information Form

2023 P

erformance Period

Total Per Capita Cost Measure Information Form (MIF)

Table of Contents

1.0 Introduction 3 .....................................................................................................................

1.1 Measure Name 3 ........................................................................................................

1.2 Measure Description 3 ................................................................................................

1.3 Measure Rationale 3 ..................................................................................................

1.4 Patient Exclusion Criteria 4 .........................................................................................

1.5 Measure Numerator 4 .................................................................................................

1.6 Measure Denominator 4 .............................................................................................

1.7 Data Sources 4 ...........................................................................................................

2.0 Methodology Steps 5 .........................................................................................................

3.0 Measure Specifications Quick Reference 6

......................................................................

Appendix A. Detailed Measure Calculation Methodology 8 .....................................................

A.1 Measure Attribution 8 .................................................................................................

Step 1: Identify Candidate Events 8 ............................................................................

Step 2: Apply Service Category and Specialty Exclusions 9 .......................................

Step 3: Construct Risk Windows 10 .............................................................................

Step 4: Attribute Beneficiary Months to TINs and TIN-NPIs 10

....................................

A.2 Measure Calculation 11 ...............................................................................................

Step 5: Calculate Payment-Standardized Monthly Observed Costs 11 ........................

Step 6: Risk-Adjust Monthly Costs 11 ..........................................................................

Step 7: Specialty Adjust Monthly Costs 13 ..................................................................

Step 8: Calculate the TPCC Measure Score 14 ...........................................................

Appendix B. Evaluation and Management “Primary Care” Services List 15 ...........................

Appendix C. Illustration of Overlapping Risk Windows Triggered by a TIN for the Same

Patient 17

.............................................................................................................................

Appendix D. Illustration of Attribution of Beneficiary Months for the TPCC Measure 19 .......

Appendix E. Example of Specialty Adjustment 21

....................................................................

Total Per Capita Cost Measure Information Form (MIF)

1.0 Introduction

This document details the methodology for the Total Per Capita Cost (TPCC) measure. The

methodology should be reviewed along with the Measure Codes List file, which contains the

medical codes used in constructing the measure.

1.1 Measure Name

Total Per Capita Cost (TPCC)

1.2 Measure Description

The TPCC measures the overall cost of care delivered to a patient with a focus on the primary

care they receive from their provider(s). The measure is a payment-standardized, risk-adjusted,

and specialty-adjusted measure. The measure is attributed to clinicians, who are identified by

their unique Taxpayer Identification Number and National Provider Identifier pair (TIN-NPI) and

clinician groups, identified by their TIN number. The TPCC measure can be attributed at the TIN

or TIN-NPI level. In all supplemental documentation, the term “cost” generally means the

standardized

Medicare allowed amount.

1.3 Measure Rationale

The TPCC measure is an important means of measuring Medicare spending, as health

expenditures continue to increase in the United States. Total health care spending is estimated

to have increased by 4.6% in 2017, reaching $3.5 trillion.

Spending for Medicare, which is still

predominantly paid on a fee-for-service (FFS) basis, grew by 3.6%, reaching $672.1 billion.

Spending on services for physicians and other health professionals totaled $69.9 billion and

accounted for 15% of Medicare FFS spending in 2016.

The TPCC measure specifically

focuses on the importance of successful payment models for primary care management.

Effective primary care management can support Medicare savings in a number of ways,

including through improvements in the treatment of chronic conditions by obviating the need for

high-cost hospital or emergency department services. More effective primary care management

can also direct a greater proportion of patients to lower hospital costs for the inpatient services.

Given the potential for decreasing spending through improvements in primary care delivery, the

TPCC measure allows for a savings opportunity by capturing the broader healthcare costs

influenced by primary care.

A TPCC measure was originally used in the Physician Value-Based Payment Modifier (VM)

Progr

am and reported in the annual Quality and Resource Use Reports (QRURs). With the

introduction of the Quality Payment Program, a version of the TPCC measure was finalized with

minor adaptations from VM and added to MIPS. The TPCC measure has undergone re-

Claim payments are standardized to account for differences in Medicare payments for the same

service(s) across Medicare providers. Payment standardized costs remove the effect of differences in

Medicare payment among health care providers that are the result of differences in regional health care

provider expenses measured by hospital wage indexes and geographic price cost indexes (GPCIs) or

other payment adjustments such as those for teaching hospitals. For more information, please refer to the

“CMS Price (Payment) Standardization - Basics" and “CMS Part A and Part Price (Payment)

Standardization - Detailed Methods” documents posted on the

CMS Price (Payment) Standard

ization

Overview page (htt

ps://www.resdac.org/articles/cms-price-payment-standardizationo

verview)

Cost is defined by allowed amounts on Medicare claims data, which include both Medicare trust fund

payments and any applicable beneficiary deductible and coinsurance amounts.

“National Health Expenditure Projections, 2017-2026.” US Centers for Medicare & Medicaid Services,

2018.

“Report to the Congress: Medicare Payment Policy.” MedPAC, 2018.

Total Per Capita Cost Measure Information Form (MIF)

evaluation to address stakeholder feedback received from prior public comment periods and

was finalized for 2020 MIPS performance period.

1.4 Patient Exclusion Criteria

Patients are excluded from the measure population if they meet any of the following conditions:

• They were not enrolled in both Medicare Part A and Part B for every month during the

perf

ormance period, unless part year enrollment was the result of new enrollment or

death.

• They were enrol

led in a private Medicare health plan (e.g., a Medicare Advantage or a

Medicare private FFS plan) for any month during the performance period.

• They resided

outside the United States or its territories during any month of the

performance period.

• They are cov

ered by the Railroad Retirement Board.

1.5 Measure Numerator

The numerator for the measure is the sum of the risk-adjusted, payment-standardized, and

specialty-adjusted Medicare Parts A and B costs across all beneficiary months attributed to a

TIN or TIN-NPI during the performance period.

1.6 Measure Denominator

The denominator for the measure is the number of beneficiary months attributed to a TIN or

TIN-NPI during the performance period.

1.7 Data Sources

The TPCC measure uses the following data sources:

• Medicare Parts A and B claims data from the Common Working File (CWF)

• Enroll

ment Data Base (EDB)

• Common

Medicare Environment (CME)

• Long Term

Care Minimum Data Set (LTC MDS)

Total Per Capita Cost Measure Information Form (MIF)

2.0 Methodology Steps

There are 2 parts to the TPCC measure calculation: attribution (Steps 1-4) and measure

calculation (Steps 5-8). This section provides a brief summary of these processes, and

Appendix A describes them in detail.

1. Identify candidate events. A candidate event identifies the start of a primary care

relationship between a clinician and patient. A candidate event is defined using select

evaluation and management (E&M) Current Procedural Terminology / Healthcare Common

Procedure Coding System (CPT/HCPCS) codes for outpatient physician visit, termed E&M

“primary care” service, paired with one or more additional service(s) indicative of general

primary care that together trigger the opening of a risk window.

Apply service category and specialty exclusions. Clinicians are excluded from attribution

if they meet the criteria for one or more service exclusions in the following categories: global

surgery, anesthesia, therapeutic radiation, and chemotherapy. Clinicians are also excluded

based on their Health Care Finance Administration (HCFA) Specialty designation, if they

identify as one or more of the 56 specialties in the specialty exclusion list.

3. Construct risk windows. The risk window begins on the date of the candidate event and

ontinues until one year after that date. A patient’s costs are attributable to a clinician during

months where the risk window and performance period overlap.

4. Attribute months to TINs and TIN-NPIs. After service category and specialty exclusions

e applied, all costs occurring during the covered months are attributed to the remaining

eligible TINs. For TIN-NPI attribution, only the TIN-NPI responsible for the majority share, or

plurality, of candidate events provided to the patient within the TIN is attributed that patient’s

costs for their respective candidate events.

Figure 1. TPCC Measure Framework

5. Calculate payment-standardized monthly observed costs. Monthly observed costs are

payment standardized to account for differences in Medicare payments for the same

service(s) across Medicare providers. All standardized cost from services starting in a

beneficiary month are assigned.

6. Calculate risk-adjusted monthly costs. Risk adjustment accounts for patient-level risk

factors that can affect medical costs, regardless of the care provided. After costs are risk-

adjusted, winsorization is applied to reduce the effect of outliers.

7. Apply specialty adjustment to risk-adjusted costs. A specialty adjustment is applied to

onthly risk-adjusted costs to account for the fact that costs vary across specialties and

across TINs with varying specialty compositions.

8. Calculate the measure score. Calculate the average payment-standardized, risk-adjusted,

and specialty-adjusted monthly costs across all beneficiary months in the performance

period attributed to a TIN or TIN-NPI for the measure score.

Total Per Capita Cost Measure Information Form (MIF)

3.0 Measure Specifications Quick Reference

This page provides a quick, at-a-glance reference for the TPCC measure specifications. The full

list of codes and logic used to define each component can be found within the Measure Codes

List file.

Candidate Event: Which patients are included in the measure?

A candidate event is defined as a pair of services billed by the clinician to the patient within a short period

of time. A candidate event marks the start of a primary care relationship between a patient and a clinician.

Risk Window: When is a clinician responsible for the patient’s costs?

Risk window is a year-long period that begins on the date of the candidate event.

Beneficiary Months Attribution: How is the TPCC measure attributed?

The performance period is a static calendar year that is divided into 13 4-week blocks called beneficiary

months. Beneficiary months that occur during a risk window and the performance period are counted

towards a clinician’s (or clinician group’s) measure scores. These beneficiary months are attributed to the

TIN billing the initial E&M “primary care” service. For TIN-NPI-level attribution, only the TIN-NPI

responsible for the plurality (largest share) of candidate events provided to the patient within the TIN is

attributed the beneficiary months.

Service Assignment: Which services are included in the measure?

TPCC is an all-cost measure.

Risk Adjustors: How does TPCC adjust for patient-level risk factors that can affect medical

costs?

Patient risk score is calculated using CMS-ESRD V21 2022 models (Dialysis New Enrollee Model,

Dialysis Continuing Enrollee Model, Community Functioning Graft Model, Institutional Functioning Graft

Model, and New Enrollee Functioning Graft Model) and CMS-HCC V24 2022 models (New Enrollee

Model, Community Model, Institutional Model).

Risk adjustors included in the CMS-HCC V24 and CMS-ESRD V21 risk adjustment models include the

following:

• Patient comorbidi

ties captured by 86 Hierarchical Condition Category (HCC) codes and 87 HCC

codes in the CMS-HCC and CMS-ESRD risk adjustment models, respectively

• Total number of patient comorbidities captured by HCCs

• Interaction variables accounting for a range of patient comorbidities

• Patient gender

• Patient dual status

• Pat

ient original reason for Medicare enrollment: age, disability and LTI status

• Patient dialysis/End-St

age Renal Disease (ESRD) status, kidney transplant and functioning graft

duration

Exclusions: Which populations are excluded from the measure?

• The patient has a primary payer other than Medicare for any month during the performance period.

•

The patient was not enrolled in Medicare Parts A and B for every month during the performance

period, unless part year enrollment was the result of new enrollment or death.

• The patient’s date of birth is missing.

• The patient’s death dat

e occurred before the performance period.

• The patient resided outside the United States or its territories during any month of the performance

per

iod.

• The patient was cov

ered by the Railroad Retirement Board.

• The clinician met the billing threshold for one or more of the following service category exclusions:

obal surgery, anesthesia, therapeutic radiation, and chemotherapy.

Total Per Capita Cost Measure Information Form (MIF)

• The clinician identified as one or more of the 56 specialties in the specialty exclusions list, based on

their HCFA Specialty designation.

Total Per Capita Cost Measure Information Form (MIF)

Appendix A. Detailed Measure Calculation

Methodology

This section describes the construction of the TPCC measure in more detail: Section A.1

outlines the construction and attribution of beneficiary months to clinicians and Section A.2

outlines measure calculation.

A.1 Measure Attribution

This section outlines in detail the following steps in measure attribution:

Step 1: Identify Candidate Events

Step 2: Apply Service Category and Specialty Exclusions

Step 3: Construct Risk Windows

Step 4: Attribute Beneficiary Months to TINs and TIN-NPIs

Step 1: Identify Candidate Events

A candidate event is used to indicate the start of a primary care relationship between a clinician

and patient and is identified by the occurrence of 2 Part B Physician/Supplier (Carrier) claims

with particular CPT/HCPCS services billed in close proximity. There are 2 different sets of

CPT/HCPCS codes used: E&M “primary care” services and primary care services.

E&M “primary care” services are a specific set of evaluation and management codes for

physician visits in the outpatient setting, physician office, nursing facility, or assisted living.

Primary care services are a broader list of services related to routine primary care and generally

fall into the following categories

• Durable Medical Equipment (DME) and Supplies

• Electrocardiogram

• Laboratory - Che

mistry and Hematology

• Other Diagnostic Procedures (I

nterview, Evaluation, Consultation)

• Other Diagnostic Radiology and Related

Techniques

• Prophylactic Vaccinations and Inoculati

ons

• Routine Chest X-ray

• Clinical Labs

• Preventive Services

Appendix B contains the list of evaluation and management “primary care” codes used in construction of

a candidate event.

The following primary care service categories are defined using the Clinical Classifications Software

(CCS) (https://www.hcup-us.ahrq.gov/toolssoftware/ccs10/ccs10.jsp) c

ategories developed by the Agency

for Healthcare Research and Quality (AHRQ): DME and supplies, Electrocardiogram, Laboratory -

Chemistry and Hematology, Other diagnostic procedures (interview, evaluation, and consultation), other

diagnostic radiology and related techniques, and Prophylactic vaccinations and inoculations.

The Clinical Labs primary care service category is defined using a subset of services included in the

Clinical Laboratory Fee Schedule (htt

ps://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Pay

ment/ClinicalLabFeeSched/index ).

The Preventive Services primary care service category is defined using the set of services CMS

considers to be part of the primary care service benefit

(https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-

QuickReferenceChart-1.html

Total Per Capita Cost Measure Information Form (MIF)

To identify a candidate event, firstly, an initial E&M “primary care” service billed on Part B

Physician/Supplier (Carrier) claim is identified. This E&M “primary care” service isn’t considered

if it occurs during a patient’s stay at a Critical Access Hospital (CAH), Inpatient Facility, or

Skilled Nursing Facility (SNF). Secondly, in addition to the initial E&M “primary care” service, at

least one of the following services should be billed to confirm the candidate event:

• From any TIN within +/- 3 days: Another primary care service

•

From the same TIN within + 90 days: A second E&M “primary care” service OR

anot

her primary care servic

See the “E&M_Prim_Care” and the “Prim_Care_Services” tabs of the TPCC Measure Codes

List file for the list of the CPT/HCPCS codes that identify E&M “primary care” services and

primary care services, respectively.

Step 2: Apply Service Category and Specialty Exclusions

Once candidate events are identified, TIN-NPIs

can be attributed based on their involvement in

the candidate event. The TIN-NPI responsible for a candidate event is found on the initial E&M

“primary care” service claim of the candidate event. Some TIN-NPIs are excluded from

attribution if they meet 1 of 2 types of exclusions: service category exclusions and specialty

exclusions. Candidate events belonging to TIN-NPIs who meet any of these exclusions are

removed from attribution and measure calculation for both the TIN-NPI and their respective TIN.

Step 2.1: Exclude Clinicians Based on Service Category Exclusions

A TI

N-NPI and their candidate events are removed from attribution if a clinician meets any of the

following 4 service category thresholds:

•

The TIN-NPI billed 10-day or 90-day global surgery services during 15% or more of

their candidate events.

•

The TIN-NPI billed anesthesia services during 5% or more of their candidate events.

•

The TIN-NPI billed therapeutic radiation services during 5% or more of their candidate

events.

•

The TIN-NPI billed chemotherapy services during 10% or more of their candidate

ents.

The steps to determine whether a TIN-NPI qualifies for the service category exclusion are as

ollows:

•

Determine the total number of candidate events that are initiated by the TIN-NPI (see

tep 1 above on how to identify candidate events).

•

For each candidate event initiated by the TIN-NPI, determine if the TIN-NPI billed an

clusion service (from the list of global surgery, anesthesia, therapeutic radiation, or

chemotherapy services) within +/-180 days of the initial E&M “primary care” service of

the candidate event to the same patient.

• Sum up the number of the candidate events identified in the step above with the

exclusion service of the same type (e.g., sum up the number of candidate events wit

he anesthesia services separately from the candidate events with the chemotherapy

services), and determine the share of those candidate events out of the total number of

candidate events.

If the share meets the threshold listed above (e.g., if more than 5% of the TIN-

NPI’s candidate events have an anesthesia service billed within +/-180 days of

Only MIPS eligible clinicians can be attributed the TPCC measure. For more information on MIPS

eligible clinicians, please see “About MIPS Participation” on the QPP website:

https://qpp.cms.gov/participation-lookup/about

Total Per Capita Cost Measure Information Form (MIF)

the initial E&M “primary care” service to the same patient), then the TIN-NPI

meets the service category exclusion and thus all candidate events belonging to

that TIN-NPI will be removed from attribution and measure calculation for both

the TIN-NPI and their respective TIN.

The list of CPT/HCPCS codes used for each of the service exclusions can be found in the tabs

of the TPCC

Measure Codes List file labelled: “HCPCS_Surgery,” “HCPCS_Anesthesia,”

“HCPCS_Ther_Rad,” and “HCPCS_Chemo.”

Step 2.2: Exclude Clin

icians Based on Specialty Exclusions

After service category exclusions are applied, clinicians who would not reasonably be

responsible f

or providing primary care are excluded from attribution of the TPCC measure. This

exclusion aims to keep primary care specialists and internal medicine sub-specialists who

frequently manage patients with chronic conditions falling in their areas of specialty. The

excluded specialties list contains 56 specialties that fall into the following broad categories:

• Surgical sub-specialt

ies

• Non-physicians without c

hronic management of significant medical conditions

• Internal medicine sub-specialt

ies with additional highly procedural sub-specialization

• Internal medicine specialties that practice primarily inpatient care without chronic care

management

• Pedi

atricians who do not typic

ally practice adult medicine

The list of HCFA Specialty codes that identify clinicians that are included or excluded from the

measure attr

ibution can be found in the “Eligible_Clinicians” tab of the TPCC Measure Codes

List.

As with service category exclusions described in Step 2.1, candidate events for clinicians in

excluded speci

alties are removed from attribution and measure calculation for both the TIN-NPI

and their respective TIN.

Step 3: Construct Risk Windows

Candidate events that are not excluded initiate the opening of a risk window, a year-long period

that begins on the date of the initial E&M “primary care” service of the candidate event. The

performance period

is divided into 13 4-week blocks called beneficiary months. Beneficiary

months during the risk window are considered attributable if they occur during the performance

period. In the event that a risk window begins or ends with a partially covered month, only the

portion during the risk window and the performance period is considered for attribution.

Appendix C contains examples of overlapping risk windows initiated by one or multiple TINs for

the same patient and explains how this overlap is addressed.

Step 4: Attribute Beneficiary Months to TINs and TIN-NPIs

Beneficiary months for a single patient are attributed to a TIN or TIN-NPI according to the

following steps:

• For attribution at the TIN level:

o Identify t

he TIN billing the initia

l E&M “primary care” service claim of each candidate

event.

The performance period is a pre-defined and static calendar year performance period.

Total Per Capita Cost Measure Information Form (MIF)

o Determine beneficiary months that fall within the risk windows of the candidate

events that were initiated by the TIN and overlap the performance period and

attribute those beneficiary months to the TIN.

• For attribution at the TIN-NPI level:

o Identify the TIN-NPI billing the initial E&M “primar

y care” service claim of each

candidate events.

o Determine beneficiary months that fall within the risk windows of t

he candidate

events that were initiated by the TIN-NPI and that overlap the performance period.

o Identify the TIN-NPI within an attributed TIN

that is responsible for the plurality of

candidate events provided to the patient. If 2 or more TIN-NPIs under a TIN provide

the same proportion of candidate events to a patient, attribute the patient to the TIN-

NPI that provided the earliest candidate event.

o Attribute only the beneficiary months fr

om candidate events that the TIN-NPI is

responsible for initiating, which is not necessarily all candidate events attributed to

the TIN for that patient.

All attributed beneficiary months for all beneficiaries are used for the measure calculation fo

each TIN and TIN-NPI.

A.2 Measure Calculation

This section outlines the following steps in measure calculation:

Step 5: Calculate Payment-Standardized Monthly Observed Costs

Step 6: Risk-Adjust Monthly Costs

Step 7: Specialty Adjust Monthly Costs

Step 8: Calculate the TPCC Measure

Step 5: Calculate Payment-Standardized Monthly Observed Costs

Monthly observed cost for attributed beneficiary months is the sum of all service costs billed for

a particular patient during a beneficiary month. Monthly observed costs are standardized to

account for differences in Medicare payments for the same service(s) across Medicare

providers. Payment standardization accounts for differences in Medicare payment unrelated to

the care provided, such as those from payment adjustments supporting larger Medicare

program goals (e.g. indirect medical education add-on payments) or variation in regional

healthcare expenses as measured by hospital wage indexes and geographic price cost indexes

(GPCIs).

Standardized costs that occur during partially covered months are pro-rated, based

on the portion of the month covered by the risk window.

Step 6: Risk-Adjust Monthly Costs

Risk adjustment accounts for patient-level risk factors that can affect medical costs, regardless

of the care provided. To ensure that the model measures the influence of health status (as

measured by diagnoses) on the treatment provided (costs incurred) rather than capturing the

influence of treatment on a patient’s health status, the risk adjustment model uses risk factors

from the year prior to a beneficiary month. Separate CMS-HCC models exist for new enrollees,

continuing enrollees, enrollees in long-term institutional settings, and enrollees with ESRD.

For more information, please refer to the “CMS Part A and Part B Price (Payment) Standardization -

Basics" and “CMS Part A and Part B Price (Payment) Standardization - Detailed Methods” documents

posted on the

CMS Price (Payment) Standardization Overview

page

(

https://www.resdac.org/articles/cms-price-payment-standardization-overview)

Total Per Capita Cost Measure Information Form (MIF)

Risk Adjustment Models

The CMS Hierarchical Condition Category Version 24 (CMS-HCC V24) 2022 Risk Adjustment

models are used for beneficiaries without ESRD. Specifically,

• The new enrollee model is used for beneficiaries that have fewer than 12 months of

edicare medical history. The model accounts for each patient’s age, sex, disability

status, original reason for Medicare entitlement (age or disability), and Medicaid

eligibility.

• The community model is used for beneficiaries that have at least 12 months of Medicare

medical history. The model includes the same demographic information as the new

enrollee model but also accounts for clinical conditions as measured by HCCs, and

various interaction terms. The community model is further broken down as follows: non-

dual aged, non-dual disabled, full-dual aged, full-dual disabled, partial-dual aged, and

partial-dual disabled.

• The institutional model is used for beneficiaries who were in long-term institutional

settings. The model includes demographic variables, clinical conditions as measured by

HCCs, and various interaction terms.

The CMS-ESRD Version 21 (CMS-ESRD V21) 2022 Risk Adjustment models are used for

ESRD beneficiaries receiving dialysis, transplant and beneficiaries with a functioning graft.

Specifically,

• The dia

lysis new enrollee model is used for ESRD beneficiaries that have fewer than 12

months of Medicare medical history. The model accounts for each patient’s age, sex,

disability status, original reason for Medicare entitlement (age or disability), Medicaid

eligibility, and ESRD.

• The dialysis continuing enrollee model is used for ESRD beneficiaries that have at least

12 months of Medicare medical history. The model includes the same demographic

information as the new enrollee model but also accounts for clinical conditions as

measured by HCCs.

• The functioning graft model, which is based on the model for the general population,

excludes HCCs for kidney transplant status and dialysis status but accounts for the

months after the transplant is received. Specifically, if a beneficiary receives a kidney

transplant, the score is calculated using the transplant model for the month of the

transplant and the two subsequent months, regardless of whether the beneficiary returns

to dialysis status during that time period. The model is further broken down into the

following:

o The new enrollee for functioning graft model is used for beneficiaries that have

fewer than 12 months of Medicare medical history. The model accounts for each

patient’s age, sex, disability status, original reason for Medicare entitlement (age

or disability), Medicaid eligibility and duration of functioning graft.

o The community for functioning graft model is used for beneficiaries that have at

least 12 months of Medicare medical history. The model includes the same

demographic information as the new enrollee model, but also accounts for

clinical conditions as measured by HCCs, various interaction terms, and duration

of functioning graft.

o The institutional for functioning graft model is used for beneficiaries who were in

long-term institutional settings. The model includes demographic variables,

clinical conditions as measured by HCCs, various interaction terms, and duration

of functioning graft.

Total Per Capita Cost Measure Information Form (MIF)

The “HCC_Risk_Adjust” tab of the Measure Codes List file lists all variables included in the

CMS-ESRD V21 and the CMS-HCC V24 risk adjustment models.

Risk Score Calculation

The CMS-ESRD V21 and CMS-HCC V24 models generate a risk score for each patient that

summarizes the patient’s expected cost of care relative to other beneficiaries. Risk scores for

patients using the CMS-ESRD V21 models are normalized to be on a comparable scale with the

HCC V24 risk scores.

• A risk score equal to one indicates risk associated with expenditures for the average

patient nationwide.

• A risk score greater than

one indicates above average risk.

• A risk score les

s than one indicates below average risk.

The risk-adjusted total for each covered month at the TIN or TIN-NPI level is calculated

accordi

ng to the following steps:

• Calculate CMS ri

sk score for each beneficiary month using diagnostic data from the

year prior to the month. This risk score is normalized by dividing by the average risk

score for all beneficiary months.

• Divide observed cos

ts for each beneficiary month by the normalized risk score to obtain

risk-adjusted monthly costs.

• Winsorize risk-adjusted monthly costs at the 99

percentile by assigning the 99

percentile of monthly costs to all attributable beneficiary months with costs above the

percentile.

• Normalize mon

thly costs to account for differences in expected costs based on the

number of clinician groups to which a patient is attributed in a given month.

Step 7: Specialty Adjust Monthly Costs

The specialty adjustment for the TPCC measure is a cost adjustment applied to account for the

fact that costs vary across specialties and across TINs with varying specialty compositions. An

example of the specialty adjustment calculation is available in Appendix E. The specialty

adjustment at the TIN and TIN-NPI levels is calculated as follows:

1. Calculate the average risk-adjusted monthly cost for each TIN and TIN-NPI by averaging

isk-adjusted monthly cost across all attributed beneficiary months. r

2. Calculate the national sp

ecialty-specific expected cost for each specialty as the weighted

average of TIN/TIN-NPI’s risk-adjusted monthly cost.

a. Define the weight for each TIN/TIN-NPI as the percentage of clinicians with that

special

ty multiplied by the total number of beneficiary months attributed to the

TIN/TIN-NPI multiplied by the number of clinicians with that specialty.

b. There will only be one specialty designation for a TIN-NPI. Therefore, the

percentage of clinicians with a specialty and number of clinicians with a specialty

will always be equal to one.

3. Calculate the specialty-adjustment factor for each TIN or TIN-NPI as follows:

a. Multiply the national specialty-specific expected cost for each specialty by the

respective specialty’s share of Part B payment within a TIN or TIN-NPI.

b. Sum the weighted s

hare of national specialty-specific expected cost calculated in

the previous step across all the specialties under a given TIN or TIN-NPI.

Specifically, monthly costs are divided by the cube root of the number of clinician groups (TINs) to

which a patient is attributed for a month.

Total Per Capita Cost Measure Information Form (MIF)

Step 8: Calculate the TPCC Measure Score

Calculate final risk-adjusted, specialty-adjusted cost measure by dividing each TIN and TIN-

NPI’s average risk-adjusted monthly cost by their specialty-adjustment factor and multiply this

ratio by the average non-risk-adjusted, winsorized observed cost across the total population of

attributed beneficiary months.

The clinician-level or clinician group practice-level measure score for any attributed clinician (or

inician group practice) “j” can be represented mathematically as:

Figure 2: TPCC Measure Score Formula

where:

Item

Description

is the beneficiary month attributed to a clinician or clinician group

practice

is the clinician or clinician group practice

is the TIN-NPI’s specialty or TIN’s specialty composition



�



is the average winsorized, normalized risk-adjusted costs across all

beneficiary months i attributed to clinician (or clinician group practice) j

is the specialty-adjustment factor for the attributed clinician (or clinician

group practice) j

is the national average per capita cost (used to convert the ratio to a

dollar amount)

A lower measure score indicates that the observed beneficiary month costs are lower than the

expected costs for the care provided by the given specialist for the particular patients and beneficiary

months included in the calculation.

A higher measure score indicates that the observed beneficiary month costs are higher than the

expected costs for the care provided by the given specialist for the particular patients and beneficiary

months included in the calculation.

Total Per Capita Cost Measure Information Form (MIF)

Appendix B. Evaluation and Management

“Primary Care” Services List

Table B below contains a list of select codes that identify E&M “primary care” services.

Table B: Evaluation and Management “Primary Care” Services List

CPT /

HCPCS

Code

CPT/HCPCS Code Description

CPT /

HCPCS

Code

CPT/HCPCS Code Description

99201

New patient office or other outpatient

visit, typically 10 minutes

99202

New patient office or other outpatient

visit, typically 20 minutes

99203

New patient office or other outpatient

isit, typically 30 minutes

99204

New patient office or other outpatient

isit, typically 45 minutes

99205

New patient office or other outpatient

visit, typically 60 minutes

99211

Established patient office or other

outpatient visit, typically 5 minutes

99212

Established patient office or other

outpatient visit, typically 10 minutes

99213

Established patient office or other

outpatient visit, typically 15 minutes

99214

Established patient office or other

outpatient, visit typically 25 minutes

99215

Established patient office or other

outpatient, visit typically 40 minutes

99304

Initial nursing facility visit, typically 25

minutes per day

99305

Initial nursing facility visit, typically 35

minutes per day

99306

Initial nursing facility visit, typically 45

minutes per day

99307

Subsequent nursing facility visit,

ypically 10 minutes per day

99308

Subsequent nursing facility visit,

ypically 15 minutes per day

99309

Subsequent nursing facility visit,

typically 25 minutes per day

99310

Subsequent nursing facility visit,

pically 35 minutes per day

99315

Nursing facility discharge day

management, 30 minutes or less

99316

Nursing facility discharge

anagement, more than 30 minutes

99334

Established patient assisted living visit,

typically 15 minutes

99335

Established patient assisted living visit,

typically 25 minutes

99336

Established patient assisted living visit,

typically 40 minutes

99337

Established patient assisted living visit,

typically 60 minutes

99339

Physician supervision of patient care at

home or assisted living facility, 15-29

minutes in one month

99340

Physician supervision of patient care at

home or assisted living facility, 30 minutes

or more in one month

99341

New patient home visit, typically 20

minutes

99342

New patient home visit, typically 30

minutes

99343

New patient home visit, typically 45

minutes

99344

New patient home visit, typically 60

minutes

99345

New patient home visit, typically 75

minutes

99347

Established patient home visit, typically 15

minutes

99348

Established patient home visit, typically 25

minutes

99349

Established patient home visit, typically 40

minutes

99350

Established patient home visit, typically 60

minutes

99441

Physician telephone patient service, 5-10

minutes of medical discussion

99442

Physician telephone patient service, 11-20

minutes of medical discussion

99443

Physician telephone patient service, 21-30

minutes of medical discussion

99490

Chronic care management services at

east 20 minutes per calendar month

CPT /

HCPCS

Code

CPT/HCPCS Code Description

Total Per Capita Cost Measure Information Form (MIF)

CPT /

HCPCS

Code

CPT/HCPCS Code Description

99318

Nursing facility annual assessment,

pically 30 minutes

99324

New patient assisted living visit,

typically 20 minutes

99325

New patient assisted living visit,

typically 30 minutes

99326

New patient assisted living visit,

pically 45 minutes

99327

New patient assisted living visit

typically 60 minutes

99328

New patient assisted living visit,

typically 75 minutes

99495

Transitional care management services,

oderately complexity, requiring face-to-

face visits within 14 days of discharge

99496

Transitional care management services,

highly complexity, requiring face-to-face

visits within 7 days of discharge

G0402

Initial preventive physical examination;

face-to-face visit, services limited to new

beneficiary during the first 12 months of

Medicare enrollment

G0438

Annual wellness visit; includes a

per

sonalized prevention plan of service

(pps), initial visit

G0439

Annual wellness visit, includes a

per

sonalized prevention plan of service

(pps), subsequent visit

Data

No Data

AMA CPT Code Description Licensing: Codes and descriptions included are from the Current Procedural Terminology (CPT®)

Total Per Capita Cost Measure Information Form (MIF)

Appendix C. Illustration of Overlapping Risk

Windows Triggered by a TIN for the Same Patient

Due to the nature of primary care, it’s possible for multiple risk windows to be initiated if one or

several TINs see the patient multiple times during the year. This appendix provides further

information on how potentially attributable beneficiary months are determined when the patient

is seen by the TIN(s) multiple times before or during the performance period.

Overlapping Risk Windows Initiated by One TIN for the Same Patient

Figure C-1 below provides an example of the interactions of multiple risk windows initiated by

the

same TIN for one patient.

Figure C- 1. Diagram of overlapping risk windows initiated for the same patient under 1 TIN

The first part of the diagram shows multiple candidate events between a TIN and a patient that

trigger the opening of overlapping risk windows. For each risk window, the months that overlap

with the performance period are attributable (indicated by a teal fill). The second part of the

diagram shows the resulting collapsed months for which the TIN will be held accountable. In this

example, all 13 beneficiary months in the performance period will be attributed to the TIN

because together, the 5 risk windows cover the entirety of the performance period. Provided

that the TIN-NPIs responsible for any of these candidate events don’t meet the service category

The attributable months identified in figures C-1 and C-2 will only be attributed to the TIN provided that

the TIN-NPI on the initial E&M “primary care” service of the candidate event doesn’t meet the service

category or specialty exclusions for this measure. If a TIN-NPI meets at least one of the service category

or specialty exclusions, the candidate events and associated beneficiary months for which they’re

considered responsible are removed from both TIN and TIN-NPI attribution

Total Per Capita Cost Measure Information Form (MIF)

or specialty exclusions, the costs assigned to these 13 beneficiary months for this patient will be

attributed to the TIN.

Overlapping Risk Windows Initiated by Multiple TINs for the Same Patient

Figure

C-2 below shows the interactions of multiple risk windows initiated by multiple TINs for

one patient, illustrating multiple attribution.

Figure C - 2. Diagram of overlapping risk window initiated by multiple TINs for the same

patient

The top part of the diagram shows multiple candidate events, each triggering the opening of a

risk w

indow. For each risk window, the months that overlap with the performance period are

attributable and are represented by teal rectangles. The bottom part of the diagram shows how

the beneficiary months will get attributed to different TINs, depending on the risk windows that

they triggered.

In the example illustrated in figure C-2, all 13 beneficiary months in the performance period are

attri

butable because together, the 4 risk windows cover the entirety of the performance period.

Since different TINs initiated the risk windows, the beneficiary months will be attributed to the

corresponding TINs in the following manner:

• TIN A initiated 2 overlapping risk window

s for the patient.

o Together these 2 risk windows

overlap with each of the 13 beneficiary months

in the performance period and, therefore, all of these 13 beneficiary months will

be attributed to TIN A.

• TIN B initiated 2 non-overlapping risk windows that partially overlap with the

perfor

mance period.

o 3 beneficiary months from the first risk window and 2 beneficiary months from

the second

risk window overlapping the performance period will get attributed to

TIN B.

Multiple attribution is intended to reflect the team-based nature of primary care, and allows attribution to

reflect changes in a patient’s primary care provider. Since the measure calculation compares each

clinician’s expected costs among their peers for patients with the same observable characteristics, rather

than to a pre-defined standard, no costs are double-counted.

Total Per Capita Cost Measure Information Form (MIF)

Appendix D. Illustration of Attribution of

Beneficiary Months for the TPCC Measure

This appendix provides further details and examples of attribution for the TPCC measure

beneficiary months.

Figure D - 2. Diagram of attribution of beneficiary months at the TIN-NPI level

In the example shown above, the stacked, colored boxes on the left represent 11 candidate

events billed by 4 different clinicians (clinician A through D) practicing under the same TIN. The

next set of boxes to the right of the colored boxes shows the specialties for each clinician and/or

whether they billed any of the services that are part of the service category exclusions at the

threshold needed to qualify for exclusion (10-day and 90-day global surgery, anesthesia,

chemotherapy, and therapeutic radiation). The set of boxes to the far right shows which

clinicians are excluded from attribution based on service category and/or specialty exclusions

and which clinicians are included.

• Clinician A bi

lled over 15% of 10-day or 90-day global surgery codes to his patients.

o Clinician A i

s excluded from attribution based on the global surgery service

category exclusion, and

o Candidate events 1 and 2 are removed from both the TIN and TIN-NPI’s

meas

ure calculation.

• Clinician B had a

n optometry HCFA specialty.

o Clinician B has

a HCFA specialty that is included in the list of 56 specialties that

are excluded from attribution, and

o Candidate events 3 through 6 ar

e removed from both the TIN and TIN-NPI’s

measure calculation.

• Clinician C didn’t meet any of the service category exclusions and had a HCFA specialty

r family practice which isn’t one of the 56 specialties excluded from the TPCC

measure.

o Clinician C i

s attributed beneficiary months overlapping the performance period

and the risk windows initiated by candidate events 7 through 10.

Total Per Capita Cost Measure Information Form (MIF)

o The resulting beneficiary months are included in both the TIN and TIN-NPI’s

measure calculation.

• Clinician D

didn’t meet any of the service category exclusions and had a HCFA specialty

for geriatric medicine which isn’t one of the 56 specialties excluded from the TPCC

measure.

o Clinician D

wasn’t attributed any beneficiary months because they didn’t bill the

plurality of candidate events for this patient within the TIN.

o Candidate event 11 will not be attributed at the TIN-NPI level, but will be

attr

ibuted at the TIN level.

Appendix E. Example of Specialty Adjustment

This appendix provides some further details and example of specialty adjustment. In this

example numbers have been rounded to the nearest whole integer for simplicity. When

calculating the measure for performance, no such rounding will occur.

1. Suppose the entire population c

onsists of 2 TINs (TIN A and TIN B) with 2 types of

specialists under them, Family Practice and Internal Medicine. Table F below provides

some additional information on the TINs’ characteristics.

Table E. TIN A and TIN B Characteristics

TIN

Average

Risk-

Adju

sted

Monthly

Cost

# of

Benefici

Months

# of

Inter

nal

Medicine

Clinicians

% of

Internal

Medicine

Clinicians

% of TIN’s

Part B

ysician/Sup

plier Cost by

of Internal

edici

Clinicians

# Family

Pract

ice

Clinicians

% of

Fami

Practice

Clinicians

% of TIN’s

Part B

hysician/S

plier Cost

by Family

Practice

Clinicians

A $1,000 110 10 20% 15%

40 80% 85%

B $800 122 48 75% 50% 16 25% 50%

2. Calculate the national specialty-specific expected cost for each specialty

a. Calculate the national Internal Medicine expected cost a

s follows:

b. Calculate the national Family Practice expected cost as follows:

3. Calculate the specialty-adjustment factor for TIN A and TIN B as the weighted average

of the national specialty-specific expected costs. The weight is the TIN’s % of Part B

Physician/Supplier payments for that specialty.

a. TIN A’s specialty-adjustment factor is calculated as follows:

($810 * 15%) + ($975 * 85%) = $950

b. TIN B’s specialty-adjustment fact

or is calculated as follows:

($810 * 50%) + ($975 * 50%) = $893

4. For each TIN, calculate the TPCC measure score (assuming

the national average cost is

$900):

a. TIN A’s measure score is calc

ulated as follows:

(($1,000 / $950) * $900 = $947

b. TIN B’s measure score is calculated as follows:

(($800 / $89

3) * $900) = $806

Total Per Capita Cost Measure Information Form (MIF)