DHCS has announced a Value-Based Payment program that will provide incentive payments to qualifying providers for meeting specific measures aimed at improving care for certain high-cost or high-need populations. These incentive payments will be targeted at providers that meet specific achievement on metrics targeting areas such as:
- Behavioral health integration
- Chronic disease management
- Prenatal/post-partum care
- Early childhood preventive care
DHCS will pay an increased incentive amount for events tied to beneficiaries diagnosed as having a substance use disorder or serious mental illness, or who are homeless.
Although final guidance to Plans regarding payment schedule, amounts and process has not yet been released, the program was implemented effective July 1, 2019, and the Alliance is informing providers so you can ensure all claims submitted include coding needed to be eligible for these additional payments.
Who is eligible for this incentive program? A Type 1 (individual) National Provider Identifier (NPI) in the rendering or ordering provider field is required on each claim that meets the measure’s
specification Encounters occurring at Federally Qualified Health Centers (FQHCs), Rural Health Clinics, American Indian Health Clinics, or Cost-Based Reimbursement Clinics are excluded from payment.
For measures involving immunizations, the expectation is that all immunizations are reported through the California Department of Public Health (CDPH) California Immunization Registry (CAIR) 2.0 and therefore are available as a supplementary data source. Similarly, for the Blood Lead Screening measure, the expectation is that blood lead test results reported to the CDPH Blood Lead Registry will be used as a supplementary data source.
An enhanced payment factor will be applied to services provided to beneficiaries with these conditions:
- Substance Use Disorder (CMS ICD-10 code set: https://www.medicaid.gov/license- agreement.html?file=%2Fmedicaid%2Fquality-of-care%2Fdownloads%2F2019-adult-value-set- directory.zip)
- Serious Mental Illness – (CMS ICD-10 codes: https://www.medicaid.gov/license- agreement.html?file=%2Fmedicaid%2Fquality-of-care%2Fdownloads%2F2019-adult-value-set- directory.zip)
- Homeless ICD-10 Diagnosis code with the following values: Z59.0 Homeless – Z59.1 Inadequate Housing.
Services eligible for payments include: prenatal and post-partum care (four measures), early childhood (five measures), adult care (five measures) and behavioral health (three measures).
The following table summarizes the services and codes for the VBP program.
| SERVICE | CODES | NOTES |
|---|---|---|
| Prenatal Pertussis Immunization | CPT 90715
With ICD-10 code for pregnancy supervision (‘O09’ or ‘Z34’ series) |
Once per delivery per patient |
| Prenatal care | ICD-10 code for pregnancy supervision (‘O09’ or ‘Z34’ series) on the encounter | Once per delivery per patient |
| Post-partum care Early 1-21 days
Late 22-84 days |
ICD-10 code for postpartum visit (Z39.2) on the encounter | Two payments possible per patient
Delivery date on claim |
| Post-partum contraception: | Tables CCP-C through CCP-D at: https://www.medicaid.gov/license- agreement.html?file=%2Fmedicaid%2Fquality-of-
care%2Fdownloads%2F2019-adult-non-hedis- value-set-directory.zip |
Provision of most effective method, moderately effective method, or long-acting reversible method of contraception within
60 days of delivery |
| Well-Child visits 0-15 months | Any of the following:
CPT: 99381, 99382, 99383, 99384, 99385, 99391, 99392, 99393, 99394, 99395, 99461, G0438, G0439 – ICD-10: Z0000, Z0001, Z00110, Z00111, Z00121, Z00129, Z005, Z008, Z020, Z021, Z022, Z023, Z024, Z025, Z026, Z0271, Z0279, Z0281, Z0282, Z0283, Z0289, Z029 |
Separate incentive payment to a provider for each of the last three well-child visits out of eight total -6th, 7th and 8th visits. (8 visits are recommended between birth and 15 months) |
| Well-child visit 3-6 years | Any of the following:
CPT: 99381, 99382, 99383, 99384, 99385, 99391, 99392, 99393, 99394, 99395, 99461, G0438, G0439 – ICD-10: Z0000, Z0001, Z00110, Z00111, Z00121, Z00129, Z005, Z008, Z020, Z021, Z022, Z023, Z024, Z025, Z026, Z0271, Z0279, Z0281, Z0282, Z0283, Z0289, Z029 |
Payment for the first well-child visit in each year age group (3, 4, 5, or 6 year olds |
| All Childhood Vaccines for Two Year Olds | Payment to rendering provider for each final vaccine administered in a series to children turning age two in the measurement year: – Diphtheria, tetanus, pertussis (DTaP) – 4th vaccine – Inactivated Polio Vaccine (IPV) – 3rd vaccine – Hepatitis B – 3rd vaccine – Haemophilus Influenzae Type b (Hib) – 3rd vaccine – Pneumococcal conjugate – 4th vaccine – Rotavirus – 2nd or 3rd
vaccine – Flu – 2nd vaccine |
A given provider may receive up to seven payments per year per patient. A two year look back is required for each patient to capture the series of vaccines and identify the last vaccine in the series |
| Blood lead screening | Each occurrence of CPT code 83655 prior to or on
the second birthday |
Provider can receive more than
one payment |
| Dental fluoride | Each occurrence of dental fluoride varnish (CPT | Oral fluoride varnish application |
| varnish | 99188 or CDT D1206) for children less than age six | for children 6 months through 5
years. Up to 4/year |
| Controlling high blood pressure | Codes for controlled systolic, a code for controlled diastolic, and a diagnosis of hypertension are: Controlled Systolic: – CPT 3074F (systolic blood pressure less than 130) – CPT 3075F (systolic blood pressure less than 130-39)
Controlled Diastolic: – CPT 3078F (diastolic blood pressure less than 80) – CPT 3079F (diastolic blood pressure less than 80-89) Hypertension: – ICD-10: I10 (essential hypertension) |
In patient age 18-85 with diagnosed HTN, payment for a non-emergent outpatient visit, or remote monitoring event, that documents controlled blood pressure Must include a code for controlled systolic, a code for controlled diastolic, and a diagnosis of hypertension on the
same day. |
| Diabetes care | Payment to rendering provider for each event of diabetes (HbA1c) testing that shows the results for members 18 to 75 years as coded with: – CPT 3044F most recent HbA1c < 7.0% – CPT 3045F most recent HbA1c 7.0-9.0% – CPT 3046F most recent HbA1c > 9.0% | Age 18-75. With diagnosis of diabetes
No more than four payments per year. Dates for HbA1c results must be at least 60 days apart. |
| Control of persistent asthma | Asthma Value set:
J45.20 Mild intermittent asthma, uncomplicated J45.21 Mild intermittent asthma with (acute) exacerbation J45.22 Mild intermittent asthma with status asthmaticus J45.30 Mild persistent asthma, uncomplicated J45.31 Mild persistent asthma with (acute) exacerbation J45.32 Mild persistent asthma with status asthmaticus J45.40 Moderate persistent asthma, uncomplicated J45.41 Moderate persistent asthma with (acute) exacerbation J45.42 Moderate persistent asthma with status asthmaticus. J45.50 Severe persistent asthma, uncomplicated J45.51 Severe persistent asthma with (acute) exacerbation J45.52 Severe persistent asthma with status asthmaticus J45.901 Unspecified asthma with (acute) exacerbation J45.902 Unspecified asthma with status asthmaticus J45.909 Unspecified asthma, uncomplicated J45.990 Exercise induced bronchospasm J45.991 Cough variant asthma J45.998 Other asthma |
Patients age 5-64. Payment to prescribing provider that provided controller asthma medications during the year for patients who had a diagnosis of asthma based on the Asthma Value Set within 12 months of the prescription. Each provider is paid once per year per patient. |
| Tobacco use screening | Payment to rendering provider for any of the following CPT codes: 99406, 99407, G0436, G0437, 4004F, or 1036F (equivalent payment for all codes) | Patients age 12 and over. One payment per provider per patient
per year. |
Additional information about the program, including the value of payments and the method in which provider payments will be processed will be forthcoming. More information is available
here: https://www.dhcs.ca.gov/provgovpart/Pages/VBP_Measures_19.aspx. Please direct any questions to Michelle Stott [email protected].
