Medicare FFS Revenue: How much will be capitated under ACO REACH?

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Abstract

There are several payment mechanisms under ACO REACH, one of which is Primary Care Capitation (PCC). This is the payment mechanism through which most primary care providers will be reimbursed. PCC applies only to Evaluation and Management (E&M) services provided to aligned beneficiaries and replaces some or all of a provider’s E&M fee-for-service (FFS) revenue. Providers will continue to receive FFS payment for non-primary care services outside the scope of the PCC payment.

As a primary care provider, you may be wondering: What portion of my FFS revenue can be attributed to E&M services? 

We break down total FFS revenue along various dimensions below.

Key Findings

Data

First, since PCC only applies to E&M services, we need to understand what qualifies as an E&M service in order to calculate how much FFS revenue will be replaced by PCC in ACO REACH.

Below is a summary of some of the most commonly billed E&M service codes that are included in PCC for ACO REACH.

Table 1: Most commonly used E&M services and billing codes
Service
Codes

HRA Administration

9616x

Home Services

9934x

Office / OP Visit