Clinical Integration Payments | April 2024 | News Flash

April 22, 2024


Clinical Integration Payments

MPP is pleased to announce the 2023 CI Payment 2 normally distributed in June was approved by the board at the April meeting and will be distributed.

Patient Care, MPP’s quality and financial performance, and your distribution, could be improved by the following:

  • Controlling costs and improving patient outcomes:
    • Practice evidence-based medicine and avoid waste and duplication of services.
    • Provide same-day access or direct provider communication with patients with acute conditions to reduce unnecessary utilization of urgent care and ED visits.
    • See patients within 7-days of hospital or SNF discharge to reduce risk of readmission.
    • Participate in MPP care coordination programs including managing patient transitions among care settings to home.
  • Improved coding:
    • Use most specific diagnosis codes to improve risk adjustment used by payors to fund gainsharing agreements.
      • Do not use unspecified diagnosis codes.
    • Document chronic conditions at least once every calendar year.
    • Engage with HCC coding tool (Stanson for Cerner EMR or Persivia CareTrak for Non-Cerner EMRs) and update diagnoses if appropriate.
    • Use CPT II codes for:
      • Documenting SBP and DBP values.
      • HgA1c if done via POC (Point of Care) testing.
      • Medication Reconciliation (if done 15-30 days after acute care discharge).
  • Improving Quality Performance:
    • Pre-visit planning using the Persivia CareView card to identify gaps in care opportunities.
    • Focusing on the entire population and not just those patients on your schedule today.
    • Use of standing orders where appropriate to allow team-based care delivery.
  • Discussing medication adherence with your patients to confirm they are taking medications as prescribed.
    • Many classes of medications need to be taken for 80% of the year (292 days) to meet the metric.
    • Use of 100-day prescriptions when possible.
    • Staff should not be asking “are your medications the same?”, they should be reviewing specific doses as they are frequently changed by specialists or during hospital admissions.
  • Performing AWV (Annual Wellness Visits) on Medicare patients
    • Great opportunity to close gaps and establish care plan with patient for the year.
    • Improves patient satisfaction with your practice.
    • Best way to attribute patients to our ACO.


For more information, please contact Dr. Michael Ziccardi, CMO, at or  (248) 484-4923.