What is Value-Based Payment Modifier?

The Value Modifier provides for differential payment to a physician or group of physicians under the Medicare Physician Fee Schedule (PFS) based upon the quality of care furnished compared to the cost of care during a performance period.  The Value Modifier is an adjustment made to Medicare payments for items and services under the Medicare PFS. It is applied at the Taxpayer Identification Number (TIN) level to physicians (and beginning in 2018, to certain non-physician eligible professionals (EPs) billing under the TIN.

Quality and Cost Measures Used in the Value Modifier

We align the Value Modifier quality measurement component with the reporting requirements under the Physician Quality Reporting System (PQRS).

The goal in aligning these programs is to: improve the quality of care for Medicare beneficiaries; provide a common base that does not increase physician reporting burden; and emphasize the importance of reporting quality performance.

To take steps to fulfill PQRS reporting requirements, please see the How to Get Started page of the PQRS Website.

In addition, the quality measurement component of the Value Modifier includes up to three outcome measures that CMS calculates from Medicare fee-for-service claims:

  1. Two composite measures of hospital admissions for ambulatory care-sensitive conditions
    • Acute conditions
    • Chronic conditions
  2. One measure of 30-day all-cause hospital re-admissions.

For the cost measure component of the Value Modifier, we include the performance of six (6) cost measures:

  1. Total Per Capita Costs for All Attributed Beneficiaries measure,
  2. Total Per Capita Costs for Beneficiaries with Specific Conditions:
    • Diabetes
    • Coronary Artery Disease
    • Chronic Obstructive Pulmonary Disease
    • Heart Failure
  3. Medicare Spending per Beneficiary (MSPB) measure (beginning with the 2016 Value Modifier).

CY 2018 Payment Adjustment – Physicians, Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists, and Certified Registered Nurse Anesthetists Who Are Solo Practitioners or in Groups of 2 or More EPs



Kevin O

About Kevin O'Sullivan

President & CEO - LL Corpus Cogere, Inc.