Keys to Success in Value-based Care Systems

By Carlos Jackson, Ph.D. and Paul Mahoney, Community Care Physician Network

2022 Alliance sponsor feature article courtesy of Community Care of North Carolina

The movement to value-based payment systems occurring simultaneously with a pandemic and, in North Carolina, sweeping changes to Medicaid, has made for an incredibly challenging environment for medical practices, particularly independent practices. This new environment requires new workflows and new approaches to managing patient panels.

The good news is that, working together, independent practices can still thrive in this new environment. In supporting the more than 900 practices in the Community Care Physician Network (CCPN), we’ve identified four critical keys to success, highlighted in the graphic below. At CCPN we work with practices where they are, share best practices pioneered by similarly-situated practices and help them find practical solutions to daily challenges.

CCPN exists to help member practices thrive financially, provide high-value care, and enable providers and patients to maximize their satisfaction with the practice of medicine. CCPN is governed by practicing, community-based physicians.

We have found that for many practices, the most challenging piece of this puzzle is making the best use of data. Practices are awash in data, but can they parse it intelligently to pull out what is actionable, and identify the information critical to hitting the metrics that drive present and future revenue?

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CCPN has made significant investments in tapping into the potential of EHR clinical data without practice staff needing to devote significant time in making sense of it all. Through new tools and innovative partnerships, we have built an infrastructure to help our network practices identify opportunities to close care gaps, improve quality and patient engagement and ultimately hit metrics that satisfy payer bonus arrangements, generating significant additional revenue critical to the long-term financial viability of the practice.

Practice PerfectSM Dashboard
Designed with busy practices in mind, Practice PerfectSM is a Tableau-based business intelligence tool that distills complex information from multiple data sources, identifying actions you can take right now to boost quality and improve performance. Recommended ActionsSM are an efficient and unique way of viewing worklists taking multiple patient and practice factors into account in order to help you prioritize long lists of care gaps.

The dashboard synthesizes claims, hospital visits, and individual risk scores to prioritize patient needs, as well analyzes the cost, utilization, and disease burden of a practice’s Medicaid patient panel. The dashboard also provides monitoring of performance on contract measures to inform practices of their progress on meeting contract measures. Users can quickly create targeted patient lists to determine where to best focus resources and improve performance. Additionally, Recommended ActionsSM integrate with clinical and scheduling data, as well as ADT and immunization feeds from outside vendors, for more actionable and up-to-date guidance. The dashboards are organized in a way to not overwhelm the provider and offer just enough information to help them be successful.

VirtualHealth™ Provider Portal
The VirtualHealthTM Provider Portal connects practices with their CCNC Care Management team – partners for improving patient outcomes. This provides secure access to Medicaid patient care management documentation, comprehensive needs assessments, and care plans. Through the portal, clinicians can make referrals to care management and enjoy secure communication with patient care teams. Clinicians can view patient history from claims, pharmacy, and hospital data – keeping them “in the know” regarding what care patients are receiving from outside their practices.

Value-based Informatics Program (VIPSM)
CCPN has significantly upgraded technology that supports practice success under value-based contracts across all payers and populations – at no additional cost to our CIN practices. We pull clinical data from practice EHRs to measure quality more easily. This greatly helps practices generate bonus payments from insurers. Our system also gathers appointment data to help practices better capitalize on Recommended ActionsSM. We alert practices to care gaps and opportunities to improve the accuracy of RAF scoring. We do this by joining EHR data with claims data for a more comprehensive view of patient care that yields improved insights. These tools also reduce administrative burden on practice staff. We are also piloting some in-line prompting tools that will provide practices with real-time alerts at the point of care. We believe that putting information in the hands of providers at the right time is one of the keys to success in value-based contracting.

While the environment for primary care practice won’t get easier anytime soon, help is available from your peers and CCNC. Together, we can help you find a path to financial strength and greater satisfaction with the practice of medicine for you, your staff, and your patients.

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Community Care Physician Network (CCPN)
CCPN is a physician-led, clinically-integrated network that helps independent primary care physicians deliver high-quality, cost-effective care. CCPN priorities are helping practices thrive financially, provide high value care, maximize provider and patient satisfaction, and take charge of their own destiny.

Value-Based Coding in a Changing Environment


With ICD-10-CM comes a new dawn in physician documentation and a much more transparent clinical footprint.  Government payers, insurers, hospitals, health systems, medical groups and others will use ICD-10’s granular data to determine accurate, fair physician compensation and reimbursement.

Diagnosis Coding is Vital to Fair Provider Compensation.   Medical groups are signing payer contracts that adjust payment for a contract year based on quality measures, outcomes, utilization and the acuity of care for a patient population. The payor measures acuity of care by reviewing the patient’s age, gender and medical conditions. Where does the payor get the list of medical conditions? Diagnosis codes on claims!  Medicare Advantage Plans base incentive payment on Risk Adjustment Factor (RAF) Scores.

Diagnosis Coding is Vital to Fair Funding to Insurance Plans. The purpose of a Risk Adjustment model is to predict the future health care costs for enrollees in Medicare Advantage plans. CMS is then able to provide capitation payments to these plans. Additional funding to the plans in the form of Capitation payments help the health plans to enroll not only healthier individuals but those with chronic conditions or who are more seriously ill.

HHS Payment Goals are to help drive the health care system towards greater value-based purchasing. Rather than continuing to reward volume regardless of quality of care delivered CMS is focused in improving outcomes and reducing cost. Alternative payment models include Accountable Care Organizations (ACOs), bundled payments, and advanced primary care medical homes. Specifically, they want to:

  • move 50% of Medicare payments into alternative payment models by the end of 2018.
  • move 90% of Medicare payments to a model tied to quality or value by 2018.

Under MACRA (Medicare Access and Chip Reauthorization Act) there is a merge of previously introduced payment incentive programs, including: 

  • Merit-Based Incentive Program (MIPS)
  • Physician Quality Reporting System (PQRS)
  • Value-Based Payment Modifier (VBM)

Clinical Practice Improvement Programs have included Meaningful use of certified EHR technology and Alternative Payment Models (APMs). From 2019-2024, some providers will receive a lump-sum payment for Increased transparency of physician-focused payment models. Starting in 2026, CMS will offer some providers higher annual payments.  APM Criteria includes coordinating care; improving quality, reducing costs.

Hierarchical Condition Category Model (HCC) affects Medicare Advantage Plans (aka Medicare Part C) which have been paid under an HCC model since 2004. HCC is a risk adjustment model which identifies patients with serious acute or chronic illnesses and assigns a risk factor score to the beneficiary based on the patient’s demographics and medical history.  The government contracts with for-profit insurers to manage health care for these patients, and pays insurers a yearly fee for each member they enroll. The higher the risk score, the higher the annual fee.

Hierarchical Condition Category Model (HCC) Calculations

Each patient is assigned a Risk Adjustment Factor (RAF) score. RAF scores are based on:

  • Patient’s age and sex
  • Medicaid or disability status
  • Total of all chronic conditions and disease interactions

RAF scores identify the patient’s health status. Lower RAF scores indicate a healthier patient and higher RAF scores indicate a sicker patient.  The Average FFS patient has a score of 1.00.

How does HCC Affect Payment? RAF scores are additive. All qualifying diagnoses are included in the RAF score. Risk factors are added to achieve total RAF scores for each patient. RAF scores are predictive, and ICD-10 codes reported this year determine payments for next year.  Remember, the payment for the RAF score is from CMS to the Medicare Advantage Plan. Then Plan distributes the incentive bonus to all providers participating in the care of the patient.  This payment is in addition to the contractual fee-for-service payments and is paid annually.

It is important to remember that the health status is re-determined each year, therefore codes must be submitted every year to be counted.  Past data is not carried forward, and the RAF for each patient is reset every year.  Also, payment is made per HCC category (not per diagnosis code). A patient with 4 ICD-10 codes from category E11 for Type II Diabetes Mellitus with complications will only receive credit once for complicated Diabetes Mellitus (HCC 18), and not 4 times that value in the RAF score.

How to Achieve Accurate RAF Payment

The Annual Health Assessment is very important. Consider implementing a program to have a staff member call all Medicare Advantage members to schedule their Annual Wellness Visit and be sure the Risk Assessment, required screenings, and status of all chronic conditions is addressed and documented to qualify as a “reportable” diagnosis.  The claim should include accurate and specific diagnosis coding.

Example of How Diagnosis Codes Affect Payment

Table1A patient is seen in your office.  Patient is a 64-year-old disabled female.  She has Type II diabetes and Diabetic Chronic Kidney Disease. The patient also has congestive heart failure and Stage IV CKD (GFR 24 ml/min Filtration).  The patient is obese with a BMI of 56, is on insulin and is paraplegic.  (see table)

Common HCC Categories

Chronic Kidney Disease
Diabetes Mellitus
Peripheral Arterial Disease (PAD)
Major Depressive Disorders
Stroke and Late effects of prior Stroke
Chronic Conditions
History of Heart Attack
Renal Dialysis Status
Tracheostomy Status
Respirator Dependence
Lower Limb Amputee
Organ Transplant Status
Asymptomatic HIV Status
Protein Calorie Malnutrition
Alcohol Dependence & Drug Dependence

What supports coding for HCC?

Use Current ICD-10 Codes. Effective October 1, 2017 the Centers for Medicare & Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) added or updated approximately 620 diagnosis codes in the 2018 ICD-10-CM coding classification.

  • 360 new codes added
  • 226 code descriptions revised
  • 34 codes changed from valid to invalid
    • Validity changes are the result of new codes being added to the classification, changing a previously valid code to an invalid code, creating a new subcategory
    • Example: a valid 4-character code now requires 5 characters
  • There are also updates to the 2018 ICD-10-CM Official Guidelines for Coding and Reporting that impact medical record documentation, code selection and sequencing.

Adherence to the Guidelines when assigning ICD-10-CM diagnosis codes is required under HIPAA in all healthcare settings.

ICD-10-CM and Documentation – Use the MEAT Acronym.  A condition is reportable when the condition was Monitored, Evaluated, Assessed or Treated.  Do not report a diagnosis code that was not addressed during the encounter or documented in the note.  Our auditors have found errors when the main note does not mention a problem, but ancillary documentation such as medication lists and referrals contains orders for those conditions. The medication list may include Prednisone 5mb PO daily for asthma, but asthma is not mentioned in the history, exam or assessment portion of the note.  Referrals for consultations and tests can be found in the note (Ex: chest x-ray confirms pneumonia) without mentioning pneumonia in the assessment portion of the note.

Steps to take in your Practice: Identify HCC Categories that are clinically meaningful. What chronic diseases do your sickest patients have?  The HCC diagnosis categories are well defined. Meet with your clinicians and decide which specific diseases/conditions are common. The ICD-10 codes are grouped to each HCC category.  There are more than 9,000 ICD-10-CM codes map to 79 HCCs in the current risk adjustment model.  Diagnosis codes are excluded from mapping when they do not predict future cost or are vague or variable in diagnosis, coding or treatment. An example is symptom codes or osteoarthritis.

Risk Adjustment Data Validation (RADV) are a reality when participating in an incentive program.  CMS audits Medicare Advantage (MA) plans for accuracy of risk-adjustment payments and compares accuracy of coding to medical record. Medicare Advantage (MA) plans can be audited annually.  MA plans audit provider records to ensure compliance.  If you are selected, you will be required to submit medical records to substantiate coding. Audits may include the entire note to verify that it supports the level of service billed, medical necessity, and all codes reported.  Common errors from RADV audits show that electronic medical record was not authenticated, or medical record does not have legible signature or appropriate credentials

Parting Thoughts.  Does your practice have a compliance program? Make it stronger by Including risk adjustment audits to validate clinical documentation. Use audit results to provide education to all clinicians and coders, and continue to audit CPT coding documentation. Continue to monitor patient visits to ensure annual reporting.

About the Author: 

Nancy M Enos, FACMPE, CPC-I, CEMC is an independent consultant with the MGMA Health Care Consulting Group.   Nancy was a practice manager for 18 years before she joined LighthouseMD in 1995 as the Director of Physician Services and Compliance Officer.  In July 2008 Nancy established an independent consulting practice.

As an Approved PMCC Instructor by the American Academy of Professional Coders, Nancy provides coding certification courses and consultative services.  Nancy frequently speaks on coding, compliance and reimbursement issues.  Nancy is a Fellow of the American College of Medical Practice Executives. She is a Past President of MA/RI MGMA.  EMAIL:

Palmetto GBA E-mail Update: Tuesday, December 15, 2015

January 2016 “Dark” Days for the Common Working File (CWF)
For the upcoming January 2016 Release, CWF will be observing one business “dark” day on Thursday, December 31, 2015. The CWF Host will also be observing the holiday on Friday, January 1, 2016, so this will also be considered a “dark” day. This means Medicare Administrative Contractors (MACs) will not have access to the Health Insurance Master Record (HIMR) and Beneficiary Dat a Streamlining (BDS) transactions. Eligibility information in HIQA and HIQH will also not be available to providers. On the dark days please use Palmetto GBA’s eServices or the Interactive Voice Response unit to eligibility and beneficiary verification for claim detail, etc. The Provider Contact Center will not have access to CWF during this time.

Applies to:

  • JM Home Health and Hospice//General
  • JM Part A//General
  • JM Part B//General

ICD-10 Post-Implementation: Coding Basics Revisited MLN Connects Video
In this Centers for Medicare & Medicaid Services (CMS) ICD-10 video, Sue Bowman from the American Health Information Management Association (AHIMA) and Nelly Leon-Chisen from the American Hospital Association (AHA) discuss the unique characteristics and features of the ICD-10 coding system.

Applies to:

  • JM Home Health and Hospice//General
  • JM Part A//General
  • JM Part B//General
  • Railroad Medicare (RRB)//General – Railroad Medicare

ICD-10 Website Wheel: A Guide to CMS Medicare FFS Resources
CMS recently released an updated ICD-10 Website Wheel for Medicare Fee-for-Service (FFS) providers. The Website Wheel provides easy access to official resources on CMS ICD-10 web pages.

Applies to:

  • JM Home Health and Hospice//General
  • JM Part A//General
  • JM Part B//General
  • Railroad Medicare (RRB)//General – Railroad Medicare

Updated eServices Minimum System Requirements Now Available
What are the minimum system requirements for Palmetto GBA’s eServices?
In an effort to maintain the security of the information available through eServices, users must now ensure that TLS 1.1 or higher is checked in their browser settings in order to successfully access the portal. This option is typically located on the Advanced tab under Internet Options in your browser. To optimize usability of Palmetto GBA’s eServices, we recommend that users verif y their system adheres to the most current version of eServices minimum system requirements. Please read this article to learn more.

Applies to:

  • JM Home Health and Hospice//General
  • JM Part A//General
  • JM Part B//General
  • Railroad Medicare (RRB)//General – Railroad Medicare
    eServices//General Information

NCMGMA-NCMSF Webinar on October 21st

NCMGM/NCMS Webinar Headeer

ICD-10: Denials and How to Work the Mounting Backlog

October 21, 2015 | 12:00 pm to 1:00pm

North Carolina Medical Society Foundation, in cooperation with the North Carolina Medical Group Management Association, invites you to join us to discuss the change from ICD-9 to ICD-10. On the day of this webinar, ICD-10 will have been live for 20 days. The change is expected to significantly increase denials. How is your practice doing? Join us for this session to learn alternative strategies for denials management and how to be proactive in overall denials reduction to decrease expenses and speed up cash flow.

Time will be reserved for questions and answers within the last fifteen minutes of the presentation.


Amy Poplin Dunatov, MPH, FACMPE, CCS-P, ICDCM-CT
Amy Dunatov has extensive experience in medical practice management, including both private practice and hospital-owned multispecialty group settings. She has comprehensive knowledge of billing and E&M coding, physician compensation plan design, financial and operational benchmarking especially as it relates to physician compensation and productivity.

Amy received her BS in Business Administration from Gardner-Webb University and a MPH from University of North Carolina School of Public Health. She has achieved fellowship status in the American College of Medical Practice Executives, the educational branch of Medical Group Management Association (MGMA). She attained certified coding specialist designation from American Health Information Management Association in 1992 and is an ICD-10-CM certified trainer.


This webinar is free but you must be registered to attend. Space is limited so register early! After you register, you will receive an emailed confirmation with webinar and phone-in instructions.

Click here to register online

Continuing education credit may be granted through your professional organization (MGMA, PAHCOM, AHIMA, etc.). Please self submit for these organizations.

Questions and More Information

For questions or more information please contact the NC Medical Society Foundation at

ICD-10 Compliance Date is Thursday, October 1st

If you are looking for information about ICD-10 compliance, you can visit this page of the BCBSNC website.  On the page you will find plenty of information to help ensure you’re covered all your bases and are ready for the October 1st deadline.

Less than 50 days until ICD-10 compliance

Originally published in the August 12, 2015 issue of MGMA’s Washington Connection
Reprinted with permission from NCMGMA

Medical groups and others are down to their last 49 days before compliance with ICD-10 diagnosis codes is required. On Oct.1, the new code set will be mandatory on healthcare claims and other HIPAA transactions. The Centers for Medicare & Medicaid Services (CMS) recently issued guidance explaining that for 12 months after ICD-10 implementation, Medicare review contractors will not deny physician claims through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code. Members are reminded, however, that regular code edits apply to claim submission, this flexibility only applies to Medicare, and a valid ICD-10 code is still required.

CMS will be hosting an MLN Connects national provider ICD-10 call on Thursday, Aug. 27 from  2:30 to 4 p.m. ET. Space may be limited, so members are advised to register early. Practice executives are urged to take advantage of MGMA and CMS ICD-10 resources as they prepare their organizations for this complex transition.

Palmetto GBA CMS eNews: Thursday, August 06, 2015

Countdown to ICD-10

  • Clarifying Questions and Answers Related to CMS/AMA Joint Announcement and Guidance Regarding ICD-10 Flexibilities — Update
  • MLN Connects National Provider Call: Countdown to ICD-10
  • Prepare for ICD-10 with MLN Connects Video

Follow this link for complete information.

Part B Ask The Contractor Teleconference: ICD-10 – August 13, 2015

Part B Ask the Contractor Teleconference: ICD-10 – Are You Ready?
Palmetto GBA will host the next Part B Ask the Contractor Teleconference (ACT) on August 13, 2015, from 10 to 11 a.m., ET. This call is intended for Part B providers and their billing staff billing for services rendered in Virginia, West Virginia, North Carolina and South Carolina. This ACT call will focus on helping providers prepare for the implementation of mandatory use of ICD-10 codes on October 1, 2015. This call will not teach providers how to code using ICD-10. Please plan to attend!  Follow this link for more information.

Applies to:

  • Jurisdiction 11 Part B//General
  • Jurisdiction 11 Part B//Physician
  • Jurisdiction 11 Part B//Primary Care
  • Jurisdiction 11 Part B//Anesthesia/Pain Management
  • Jurisdiction 11 Part B//Cardiovascular
  • Jurisdiction 11 Part B//Pathology & Laboratory
  • Jurisdiction 11 Part B//Hematology/Oncology
  • Jurisdiction 11 Part B//Non-Physician Practitioners
  • Jurisdiction 11 Part B//Physical/Occupational Therapy

CMS to Permit Non-specific ICD-10 Codes for One Year

The Centers for Medicare & Medicaid Services (CMS) announced a set of new policies related to the Oct. 1, 2015 transition to ICD-10. For the first year that ICD-10 is in place, Medicare claims will not be denied, and eligible professionals will not be penalized under PQRS, the value-based payment modifier or meaningful use based solely on the specificity of the diagnosis codes, as long as they are from the appropriate “family” of ICD-10 codes. In addition, CMS will authorize advance payments to physicians should Medicare contractors be unable to process claims as a result of ICD-10 complications. The Agency also announced plans to create a new communication center to monitor and resolve issues as quickly as possible, as well as an “ICD-10 Ombudsman” to assist providers. In a separate announcement, CMS indicated that nationally it accepted 90% of claims from more than 1,200 submitters who participated in CMS’ third round of ICD-10 “front end” (acknowledgement) testing.

NCTracks Update: May 26, 2015

ICD-10 Updates

Multi-Payer Provider Expos June 25 and August 6
There are two upcoming Multi-Payer Provider Expos. There will be a Multi-Payer Provider Expo on Thursday, June 25, 2015, at the LaQuinta Inn & Suites Hickory, 1607 Fairgrove Church Rd., Conover, NC. There will also be a Multi-Payer Provider Expo on Thursday, August 6, at the Doubletree Asheville – Biltmore, 115 Hendersonville Rd., Asheville, NC.

The Multi-Payer Provider Expos are held from 8:00 a.m. to 1:00 p.m. The events are co-sponsored by BlueCross BlueShield of NC, Humana, Medcost, United Healthcare, and the NC Department of Health and Human Services. The event is for Physicians, Practice Managers, and Staff, and will include guest speakers and an opportunity to talk with each of the healthcare payers about ICD-10 and the Affordable Care Act.

For more information and to register to attend, see the links to the Expo forms below. The forms can also be found under the heading Quick Links on the ICD-10 page of the NCTracks Provider Portal.

For More Information
Find your ICD-10 codes on the NCTracks ICD-10 Crosswalk at, Send your questions about the NCTracks transition to ICD-10 codes to We will share frequently asked questions with all.