Specific Primary Care Services Included in the Prospective Payment

Specific primary care services included in the prospective payment

The Primary Care VBP Model envisioned by the VBP Compact Workgroup is anticipated to include the following services and codes within per member per month (PMPM) capitation payments to primary care practices:

  1. Office or outpatient visit for an established patient (99211-99215)
  2. Office or outpatient visit for a new patient (99202-99205)
  3. Telephone calls for patient management (99441-99443)
  4. Prolonged physician services (99354, 99355, 99358- 99360)
  5. Preventive medicine counseling or risk reduction intervention (99401-99404)
  6. Preventive medicine counseling initial evaluation (99381-99387)
  7. Preventive medicine periodic re-evaluation (99391-99429)
  8. Administration of immunizations (90460, 90461, 90471-90474)
  9. Transitional care management services (99495, 99496)
  10. Medical team conference (99366-99368)
  11. Therapeutic, prophylactic or diagnostic injection (96372)
  12. Group preventive medicine counseling or risk reduction intervention (99411, 99412)
  13. Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5–10 minutes, 11-20 minutes, 21 or more minutes (99421, 99422, 99423)
  14. Non-face-to-face online medical evaluation (99444)
  15. Non-physician telephone services (98966, 98967)
  16. Online assessment, management services by non-physician (98969)
  17. Annual wellness visit, personalized prevention plan of service (G0438, G0439)
  18. Comprehensive geriatric assessment and treatment planning performed by assessment team (S0250)
  19. Telephone calls by a registered nurse to a disease management program member for monitoring purposes; per month (S0320)

The above list of codes is typical of codes included in primary care capitation contracts by Medicaid and commercial payers in Oregon. Practices should anticipate that any code not specifically included in the primary care capitation payments is excluded from the PMPM amount and could be billed separately by the practice where appropriate.