I know there are people out there who eat, sleep, and breathe Excel spreadsheets of clinical codes. God bless you if you are one of those people! That means we need you to comment on the design of the cost measure for “non-pressure ulcers.” I’ve provided the links to background materials and the zip files that include the measure specifications. Obviously, the files you care about are those labeled, “npr-ulcers” (a PDF and Excel spreadsheet).

I pasted below the survey questions that you’ve been asked to address so you can read through them before you start the survey. To actually answer the questions and provide feedback, you will need to access the actual survey here: 2024 Field Testing Feedback Survey. While you can skip all the questions and just submit a letter, I am sure that CMS and the Acumen team hope your letter will provide insights to these specific questions.

 I hope that being able to read through the survey questions pasted below will help folks understand this whole exercise a bit better, and exactly what they need to focus on when they review the Excel spreadsheet.

Also, to understand why we need a “good” cost measure for chronic wounds, read this old blog post from 2109 in which I explain the way that my cost measure in the QPP was determined by any hospitalization of a chronic wound patient for myocardial infarction, congestive heart failure, urinary tract infections, exacerbation of chronic obstructive pulmonary disease, GI hemorrhage, ischemic stroke, pneumonia, and cellulitis in a diabetic patient WITHOUT A WOUND. I would much rather have Medicare evaluate my spending in a chronic wound patient (spending which I actually control) than hold me accountable for the list of conditions above – just because I am a family practice doctor who sees chronically ill patients frequently. If Medicare is going to hold me accountable for the cost of patients care (and they will), please let it be for the problems that I am actually treating.

–Caroline

• Current cost measure activities | CMS
• 2024 Episode-Based Cost Measures Field Testing Wave 6 Measure Development Process (cms.gov)
• https://www.cms.gov/files/zip/2024-02-wave-6-ft-measure-specs.zip
  (you will get the files below and naturally the two that are relevant are labeled “npr-ulcers”)

 

1. Trigger codes are used to identify a clinician-patient relationship and define the patient cohort. Two codes (trigger and confirming claim) must be billed by the same group practice (TIN) within 1 and 180 days of each other to establish this relationship.

• For the draft Non-Pressure Ulcers measure, a trigger claim, which marks the start of an episode, is a Part B Physician/Supplier claim for a clinically relevant outpatient service when paired with an ICD-10 diagnosis code indicating a non-pressure ulcer. These outpatient services can be summarized as:
  • Outpatient evaluation and management (E/M)
  • Measure-specific E/M
• A confirming claim, which indicates the continuation of a patient-clinician relationship, is a second Part B Physician/Supplier claim. The draft measure uses another outpatient E/M, measure-specific E/M or any of the following confirming services when paired with a non-pressure ulcer diagnosis:
  • Rehabilitation service
  • Debridement
  • Skin grafts and flaps
  • Wound dressing products
  • Wound modalities (e.g., vacuum assisted closure)

Refer to the Measure Codes List to see a more detailed list of the CPT/HCPCS codes used to trigger and confirm a Non-Pressure Ulcers episode (“Triggers_HCPCS” tab).

Do the trigger codes appropriately identify a patient cohort that reflects the measure intent? If not, what changes should be made to ensure that the measure has strong potential to impact spending for a comparable patient cohort? Note that patient heterogeneity within this overall patient cohort can be addressed through other parts of the measure construction (e.g., exclusions, risk adjustment).

2. When the beginning of a patient-clinician relationship has been identified and a Non-Pressure Ulcers episode has been defined, it is attributed to individual clinicians (TIN-NPIs) and TINs. A Non-Pressure Ulcers episode should be attributed to TIN-NPIs or TINs who reasonably influence the frequency, intensity, or occurrence of the clinically related services provided to a patient.  While various specialties may be involved in managing and treating patients with non-pressure ulcers, some specialties may be more influential in non-pressure ulcer care than others. Similarly, some clinicians may have more influence over the frequency and intensity of services provided to a patient than others, even those within the same specialty or group practice.

For instance, physical and occupational therapy services can confirm a care relationship but not trigger one on their own, such that physical/occupational therapists may be attributed as a part of a clinician group practice. This is because physical/occupational therapists develop care plans and provide treatment services for non-pressure ulcers, such as those in multidisciplinary facilities/practices, but outside of such practices, may have less influence over the frequency, intensity, or occurrence of clinically related services. For a more detailed description of how we define and attribute episodes, please reference Section 4 of the draft Measure Information Form (MIF).

How can the Non-Pressure Ulcers measure best attribute episodes to clinicians or group practices who reasonably influence the frequency, intensity, or occurrence of the clinically related services provided to a non-pressure ulcer patient?

3. The draft Non-Pressure Ulcers measure stratifies episodes into more granular, mutually exclusive, and exhaustive patient cohorts (i.e., sub-groups) based on ulcer type such that a separate regression for the measure score is run for each type. These include:

• Diabetic Ulcer (i.e., episodes with diagnosis codes indicating only diabetic ulcers)
• Arterial Ulcer (i.e., episodes with diagnosis codes indicating only arterial ulcers)
• Venous Ulcer (i.e., episodes with diagnosis codes indicating only venous ulcers)
• Multiple Ulcers (i.e., episodes with diagnosis codes indicating at least 2 different types of ulcers)
• Non-specific Ulcer (episodes with no diagnosis codes for diabetic, arterial, or venous ulcers, and characterized by only chronic non-pressure ulcers diagnoses, i.e., L97/L98 ICD-10 codes)

Sub-grouping by ulcer type also ensures we fairly compare clinicians with a similar patient case mix. The current sub-grouping methodology identifies ulcer type based on ulcer diagnoses in the 120-day lookback period, including the episode start date.  For more information on the sub-grouping methodology, please reference Appendix B in the draft MIF.

Refer to the Measure Codes List to see a detailed list of the codes used to create sub-groups for the measure (“Sub_Groups_Details” tab).

Is ulcer type a good indicator of patient heterogeneity and resource use in caring for patients with non-pressure ulcers? Are there any additional claims-based indicators of resource use we should consider when sub-grouping for the Non-Pressure Ulcers measure?

4. The draft Non-Pressure Ulcers measure includes clinically related services that encompass variations in treatment options, the intensity or duration of treatment, routine care and monitoring, acute exacerbations, complications, side effects from treatment, and supportive care. The goal is to include broad enough sets of services such that the measure captures variation in care while still being refined enough to focus on condition-related costs. Clinicians and other interested parties have also pointed out that simpler service assignment rules make the measures easier to understand.

The Non-Pressure Ulcers measure currently includes the following service categories:

• Outpatient E/M services
• Inpatient hospital services (e.g., amputations, skin grafts and debridement, hospitalizations for cellulitis, hospitalizations for osteomyelitis)
• Physician services during hospitalization
• Imaging services (e.g., x-ray, ultrasound, CT scan)
• Major/minor procedures (e.g., skin procedures, joint injections, hyperbaric oxygen, vascular procedures)
• Physical, occupational, or speech and language pathology therapy
• Post-acute care services
• Emergency department services
• Durable medical equipment and supplies (e.g., skin allograft, orthotic devices, wheelchairs and accessories, oxygen and supplies)
• Part B covered drugs (e.g., nononcologic injections and infusions)
• Part D services (i.e., antibiotics, wound care products, bandages, gauze pads, and dressings)

Should any of the service categories (listed above) be refined (e.g., are there specific services that should be added to or removed from the measure)? Please explain your rationale.

Are there any additional service categories we should consider for service assignment for the Non-Pressure Ulcers measure? Please explain your rationale.

5. MIPS episode-based cost measures use a robust risk adjustment model to account for factors deemed outside the reasonable influence of the attributed clinician or group practice. The risk adjustment model includes a standard set of risk adjustors used across cost measures from the CMS Hierarchical Condition Category (CMS-HCC) model. This includes comorbidities captured by 86 HCC codes that map with thousands of ICD-10-CM codes, and other standard risk adjustors, including interaction variables accounting for a range of comorbidities, patient-level demographics (i.e., age) and health status (i.e., disability status, end-stage renal disease [ESRD] status, recent use of long-term care), patient dual eligibility status, and types of clinician specialties from which the patient has received care. Specific to the draft Non-Pressure Ulcers measure, the risk adjustor variables include smoking and frailty indicators.

Refer to the Measure Codes List to see more information on the standard and measure-specific risk adjustors for the measure (“RA” and “RA_Details” tabs).

Please note that the risk adjustors should meet the following conditions:

• Present at the start of care
• Clinical/conceptual relationship with the outcome of interest (i.e., is this cohort different in a way that affects costs?)
• Variation in the prevalence of the factor
• Is not an indicator of the care provided to a patient
• Resistant to manipulation or gaming
• Not redundant with other variables
• Service assignment mitigates need to adjust for unrelated heterogeneity

Are there any changes that should be made to the current list of standard and measure-specific risk adjustors (such as adding or removing variables)? Are there additional patient-level indicators we should account for in risk adjustment?

6. Exclusions remove small sets of patients where there is extreme variability that is not susceptible to performance improvement. More complex patients may have higher costs, but this complexity can be addressed through risk adjustment and service assignment to include only those costs of services or items that are clinically related to the attributed clinician’s role in managing care during a Non-Pressure Ulcer episode. There may also be greater opportunities to improve care and impact Medicare spending with more complex patients. The draft Non-Pressure Ulcers measure excludes the following patient cohorts:

• Patients with pyoderma gangrenosum
• Patients with calciphylaxis
• Patients with sickle cell anemia
• Patients with vasculitis
• Patients with scleroderma

Should there be any changes made to the current list of excluded episodes for the Non-Pressure Ulcers measure? Please specify.

7. The intent is for the Non-Pressure Ulcers measure to be used in the MIPS Cost performance category. If added to MIPS in the future, it would be one part of the MIPS final score; the other performance categories are quality measures, improvement activities, and promoting interoperability.

Which quality measures are the most relevant to the Non-Pressure Ulcers measure to assess the value of care?

The draft Non-Pressure Ulcers measure includes clinically related services that encompass variations in treatment options, the intensity or duration of treatment, routine care and monitoring, acute exacerbations, complications, side effects from treatment, and supportive care. The goal is to include broad enough sets of services such that the measure captures variation in care while still being refined enough to focus on condition-related costs. Clinicians and other interested parties have also pointed out that simpler service assignment rules make the measures easier to understand.

The Non-Pressure Ulcers measure currently includes the following service categories:

• Outpatient E/M services
• Inpatient hospital services (e.g., amputations, skin grafts and debridement, hospitalizations for cellulitis, hospitalizations for osteomyelitis)
• Physician services during hospitalization
• Imaging services (e.g., x-ray, ultrasound, CT scan)
• Major/minor procedures (e.g., skin procedures, joint injections, hyperbaric oxygen, vascular procedures)
• Physical, occupational, or speech and language pathology therapy
• Post-acute care services
• Emergency department services
• Durable medical equipment and supplies (e.g., skin allograft, orthotic devices, wheelchairs and accessories, oxygen and supplies)
• Part B covered drugs (e.g., nononcologic injections and infusions)
• Part D services (i.e., antibiotics, wound care products, bandages, gauze pads, and dressings)

Should any of the service categories (listed above) be refined (e.g., are there specific services that should be added to or removed from the measure)? Please explain your rationale.

8. Are there any additional service categories we should consider for service assignment for the Non-Pressure Ulcers measure? Please explain your rationale.

MIPS episode-based cost measures use a robust risk adjustment model to account for factors deemed outside the reasonable influence of the attributed clinician or group practice. The risk adjustment model includes a standard set of risk adjustors used across cost measures from the CMS Hierarchical Condition Category (CMS-HCC) model. This includes comorbidities captured by 86 HCC codes that map with thousands of ICD-10-CM codes, and other standard risk adjustors, including interaction variables accounting for a range of comorbidities, patient-level demographics (i.e., age) and health status (i.e., disability status, end-stage renal disease [ESRD] status, recent use of long-term care), patient dual eligibility status, and types of clinician specialties from which the patient has received care. Specific to the draft Non-Pressure Ulcers measure, the risk adjustor variables include smoking and frailty indicators.

Refer to the Measure Codes List to see more information on the standard and measure-specific risk adjustors for the measure (“RA” and “RA_Details” tabs).

Please note that the risk adjustors should meet the following conditions:

• Present at the start of care
• Clinical/conceptual relationship with the outcome of interest (i.e., is this cohort different in a way that affects costs?)
• Variation in the prevalence of the factor
• Is not an indicator of the care provided to a patient
• Resistant to manipulation or gaming
• Not redundant with other variables
• Service assignment mitigates need to adjust for unrelated heterogeneity

Are there any changes that should be made to the current list of standard and measure-specific risk adjustors (such as adding or removing variables)? Are there additional patient-level indicators we should account for in risk adjustment?

9. Exclusions remove small sets of patients where there is extreme variability that is not susceptible to performance improvement. More complex patients may have higher costs, but this complexity can be addressed through risk adjustment and service assignment to include only those costs of services or items that are clinically related to the attributed clinician’s role in managing care during a Non-Pressure Ulcer episode. There may also be greater opportunities to improve care and impact Medicare spending with more complex patients. The draft Non-Pressure Ulcers measure excludes the following patient cohorts:

• Patients with pyoderma gangrenosum
• Patients with calciphylaxis
• Patients with sickle cell anemia
• Patients with vasculitis
• Patients with scleroderma

Should there be any changes made to the current list of excluded episodes for the Non-Pressure Ulcers measure? Please specify.

10. The intent is for the Non-Pressure Ulcers measure to be used in the MIPS Cost performance category. If added to MIPS in the future, it would be one part of the MIPS final score; the other performance categories are quality measures, improvement activities, and promoting interoperability.

Which quality measures are the most relevant to the Non-Pressure Ulcers measure to assess the value of care?

Section 2: Field Testing Questions

Field Test Reports

If you did not receive a field test report, you can review a mock field test report to see what metrics are provided.

1. The field test reports contain a number of tables with information about cost performance. One such table provides a breakdown of costs by Restructured BETOS Classification System (RBCS) (where BETOS is Berenson-Eggers Type of Service categories, a classification system for services commonly used in research). Here, RBCS categories have been adapted/augmented for the purposes of field testing through added granularity related to each measure undergoing testing. These costs are compared to the national average and providers with a similar patient case-mix.

• Was it helpful to have both types of service categories in the report, or was one more informative than the other?
• Across these tables, which are the most useful service categories for helping you to understand your cost performance and identify potential practice changes?
• Are there different types of service or cost breakdowns that would be useful (e.g., more or less granular)?
• How important is it to have standardized metrics across measures, since clinicians may receive multiple field test reports?
• Are there other comparisons beside national average and providers with similar patient case-mixes that would be useful for understanding your cost performance?

2. The field test reports (PDF and CSV) contain information about other providers who contribute cost to your measure. How useful are the current metrics in helping review referral patterns and care coordination opportunities which could help lower costs? What other metrics would be useful to encourage care coordination?

3. Please provide comments about the presentation, content, and clarity of the sections within the Episode-Based Cost Measure Field Test Report listed below. Include any suggestions on how we can improve its readability, usefulness, and actionability of the information presented in these sections.

• Overview and Results
• Comparison of your score to the national distribution
• Breakdown of Cost Measure Performance
• Additional Information
• CSV with episode-level results

4. What information was the most useful for helping you to understand your cost measure performance?

• Mock field test reports
• Draft measure specifications
• Field testing FAQ
• CSV with patient-level information
• Measure Testing Forms

5. What other feedback do you have about the field test reports?

Technical Specifications

6. The draft measure specifications include various components: measure construction methodology, quick reference specifications, measure flowchart, and codes list. Which part of the specification documentation do you find the most useful for understanding the measure?

• Measure construction methodology
• Quick reference specifications
• Measure flowcharts
• Codes list

Education and Outreach

7. How did you find out about field testing?

• Received CMS email notification
• Received Acumen email notification
• Attended field testing webinar
• Was notified by specialty society / professional association
• Was notified by clinical practice
• Saw on the CMS MACRA website
• Other (specify)