Da Vinci Value-Based Performance Reporting Implementation Guide
1.0.0 - STU1 United States of America flag

This page is part of the Da Vinci Value-Based Performance Reporting Implementation Guide (v1.0.0: STU1) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

CodeSystem: Performance Metric Codes

Official URL: http://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metric Version: 1.0.0
Active as of 2024-06-17 Computable Name: VbpPerformanceMetricsCS
Other Identifiers: OID:2.16.840.1.113883.4.642.40.30.16.9

Type of value-based performance metrics.

This Code system is referenced in the content logical definition of the following value sets:

This case-sensitive code system http://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metric defines the following codes:

CodeDisplayDefinition
avg-risk-score Average risk score Average risk score is a numeric score where a higher score indicates a riskier population on average. Example scores: 0.70, 1.00, 1.30.
avg-risk-score-market Market average risk score The market average risk score.
capitation Capitation Total capitation amount.
capitation-pmpm Capitation per member per month Capitation per member per month (PMPM). Capitation is a fixed amount of money per patient per month paid in advance to the physician [or health care provider] for the delivery of health care services.
dental-capitation Dental capitation Total dental capitation.
dental-capitation-pmpm Dental capitation PMPM Total dental capitation per member per month (PMPM).
reinsurance-capitation Reinsurance capitation Total reinsurance capitation.
reinsurance-capitation-pmpm Reinsurance capitation PMPM Reinsurance captitation per member per month (PMPM).
ccf Care coordination fee Care coordination fee (CCF) is per member per payments based on the number of patients that are assigned to primary care physicians.
goal-hcc-raf Goal HCC RAF Goal or target hierarchical condition category (HCC) Risk Adjustment Factor (RAF).
actual-hcc-raf Actual HCC RAF Acutal hierarchical condition category (HCC) Risk Adjustment Factor (RAF).
earnings-ccf Earnings CCF Earnings from care coordination fees.
performance-ccf Performance CCF Performance for care coordination fees.
potential-upside-ccf Potential upside CCF Potential upside earnings for care coordination fees.
potential-downside-ccf Potential downside CCF Potential downside earnings for care coordination fees.
earned-incentive Earned incentive Earned incentive payment.
earnings-qip Earnings QIP Earnings from quality incentive payments.
performance-qip Performance QIP Performance for quality incentive payments.
potential-upside-qip Potential upside QIP Potential upside earnings for quality incentive payments.
potential-downside-qip Potential downside QIP Potential downside earnings for quality incentive payments.
earnings-ssl Earnings SSL Earnings from shared savings surplus/loss.
performance-ssl performance SSL Performance for shared savings surplus/loss.
potential-upside-ssl Potential upside SSL Potential upside earnings for shared savings surplus/loss.
potential-downside-ssl potential downside SSL Potential downside earnings for shared savings surplus/loss.
earnings-cap Earnings capitated Earnings from capitated payments.
performance-cap Performance capitated Performance for capitated payments.
potential-upside-cap Potential upside capitated Potential upside earnings from capitated payments.
potential-downside-cap Potential downside capitated Potential downside earnings for capitated payments.
quality-gate-percentage Quality gate percentage % of payment tied to quality.
quality-gate-performance-percentage Quality gate performance percentage % of shared savings can earn based on quality metric performance.
interim-pmt-rate Interim payment rate Interim payment rate.
ibnr-pmpm IBNR PMPM Incurred but not yet reported (IBNR) per member per month (PMPM).
med-ibnr Medical IBNR Estimated medical expenses incurred but not yet reported (IBNR).
rx-ibnr Pharmacy IBNR Estimated pharmacy expenses incurred but not yet reported (IBNR).
med-rx-ibnr Medical pharmacy IBNR Estimated medical and pharmacy expenses incurred but not yet reported (IBNR).
revenue Revenue Total revenues earned, which includes premiums and other resources that a payer receives.
revenue-pmpm Revenue PMPM Revenue earned per member per month (PMPM).
avg-revenue-pmpm-market Market average revenue PMPM Average revenue per member per month (PMPM) for a market.
cost-target Cost target Cost target.
admin-cost Administrative cost A general term that refers to Medicare and Medicaid administrative costs, as well as CMS administrative costs. Medicare administrative costs are comprised of the Medicare related outlays and non-CMS administrative outlays. Medicaid administrative costs refer to the Federal share of the States' expenditures for administration of the Medicaid program. CMS administrative costs are the costs of operating CMS (e.g., salaries and expenses, facilities, equipment, rent and utilities, etc.). These costs are reflected in the Program Management account.
rx-cost Pharmacy cost Total amount of the pharmacy cost.
rx-cost-target Pharmacy cost target The goal or target pharmacy spend level as specified by a value-based contract below which savings are generated, often represented as a percent of total revenue.
rx-cost-pmpm Pharmacy cost PMPM Pharmacy cost per member per month (PMPM).
rx-cost-pmpm-target Pharmacy cost PMPM target The goal or target pharmacy spend level per member per month (PMPM) as specified by a value-based contract below which savings are generated, often represented as a percent of total revenue.
med-cost Medical cost Total amount of the medical cost.
med-cost-target Medical cost target The goal or target medical spend level as specified by a value-based contract below which savings are generated, often represented as a percent of total revenue.
med-cost-pmpm Medical cost PMPM Medical cost per member per month (PMPM).
med-cost-pmpm-target Medical cost PMPM target The goal or target medical cost per member per month (PMPM).
med-cost-fund Medical cost fund Total dollars available for medical spend calculated using the medical cost target relative to estimated revenue.
avg-med-cost-fund-market Market average medical cost fund The market average medical cost per member per month (PMPM) over revenue PMPM.
med-rx-cost Medical pharmacy cost Total spend on medical and pharmacy cost for a specified population.
med-rx-cost-target Medical pharmacy cost target Target spend on medical and pharmacy cost for a specified population.
med-rx-cost-pmpm Medical pharmacy cost PMPM Total spend on pharmacy cost for a specified population represented on a per member per month (PMPM) basis.
avg-med-rx-cost-pmpm-market Market average medical pharmacy cost PMPM The market average medical pharmacy cost per member per month (PMPM).
variance-cost Variance cost How much actual costs vary from projected (target) costs.
med-loss-ratio Medical loss ratio The Medical Loss Ratio (MLR) is the proportion of premium revenues spent on clinical services and quality improvement.
med-loss-ratio-target Medical loss ratio target The goal or target medical spend level relative to revenue as specified in a value-based care contract, often represented as a percent of revenue.
med-expense-ratio Medical expense ratio Medical expense ratio.
med-expense-ratio-pmpm Medical expense ratio PMPM Medical expense ratio per member per month (PMPM).
member-months Member months Total member months in a given period.
med-member-months Medical member months Total medical member months in a given period.
rx-member-months Pharmacy member months Total pharmacy member months in a given period.
adjusted-paid-claim Adjusted paid claim Adjusted paid claim, excludes catastrophic claims.
annual-care-visit-bonus Annual care visit bonus Bonus to qualified annual care visit (ACV). A type of quality incentive payment.
avg-star-rating-bonus Average star rating bonus Bonus earned when achieve a certain Average Star Rating. A type of quality incentive payment.
avg-star-rating-improvement-bonus Average star rating improvement bonus Bonus earned when achieve improvement performance year over year based on average star rating. A type of quality incentive payment
quality-metric-performance-incentive Quality metric performance incentive Quality metric performance incentive payment is a type of quality incentive payment.
quality-pmt-chronic Quality payment chronic disease management Quality payment chronic disease management.
quality-pmt-office-visit Quality payment annual office visit Quality payment annual office visit.
shared-saving-deficit Shared saving deficit The amount of shared saving deficit.
weighted-avg-star Weighted average star The average quality score across a specified set of measures, weighted by importance of the individual measures for a specific population. Often used in relation to CMS Medicare Star rating reports, e.g., where medication adherence measures are 3x weighted relative to other quality measures in the set.
condition-count Condition count The number of conditions.
1-gap-closed 1 gap closed Number of members with 1 closed gap.
2-gap-closed 2 gaps closed Number of members with 2 closed gaps.
paid-claim Paid claim Total paid claim amount.
paid-claim-pmpm Paid claim PMPM Paid claim per member per month (PMPM).
drg-expense DRG expense Total diagnosis related group (DRG) expense.
drg-expense-pmpm DRG expense PMPM Diagnosis related group (DRG) expense per member per month (PMPM).
provider-quality-expense-pmpm Provider quality expense PMPM Provider quality expense per member per month (PMPM).
subrogation-pmpm Subrogation PMPM Subrogation per member per month (PMPM).
avg-member-office-visit Average members with office visit Average number of members with office visit.
ed-visit ED visit Total number of Emergency Department (ED) visits.
eligible-member Eligible members Total number of eligible members.
inpatient-acute Inpatient acute Total number of inpatient acute stays.
inpatient-admission Inpatient admission Total number of inpatient admissions.
nurse-hotline Nurse hotline Total number calls of the nurse hotline.
nurse-hotline-pmpm Nurse hotline PMPM Total nurse hotline per member per month (PMPM).
snf-avg-los Skilled Nursing Facility average length of stay The number of skilled nursing facility average length of stay.
readmission Readmission Total number of readmissions
snf-admission Skilled Nursing Facility admission Total number of skilled nursing facility admissions.
provider-quality-expense Provider quality expense Total provider quality expense.
subrogation Subrogation Total subrogation amount.
avg-membership Average membership Average membership.