How Will CMS Bundled Payment Programs Shape Your Coding?

Know the Issues BPCI Advanced Raises for How You Claim Reimbursement

The way you’re reimbursed for the services you provide is changing.

Increasingly, fee-for-service (FFS) models are giving way to bundled payment models. These models reward quality, not quantity, of services. They emphasize value over volume, and encourage providers to coordinate care across specialties and settings.

CMS bundled payment programs have also, according to agency data, proven financially rewarding for many participating providers. Modern Healthcare analyzed statistics from hospitals, for instance, and reported, “Nearly half the 799 participating facilities across the country—47.8%—received gain-sharing payments for meeting the bundled-payment program’s cost and quality targets” in April-December 2016.

As CMS introduces a new bundled payment program this year—the largest bundled payment program any payer has yet put forward—we at MDCodePro offer a brief overview of it and its implications for your accurate, compliant, and revenue-generating medical coding.


The Basics of CMS BPCI and BPCI Advanced

The CMS Innovation Center allows Medicare and Medicaid “to test models that improve care, lower costs, and better align payment systems to support patient-centered practices.” In 2013, the Innovation Center introduced the voluntary Bundled Payments for Care Improvement Initiative (BPCI).

cms bundled payment programIn this model, Medicare doesn’t pay BPCI participants separately for each service provided to treat a patient’s condition during a specific time period, or clinical episode of care. Instead, as the Kaiser Family Foundation explains, “Medicare establishes a total budget for all services… If the episode’s spending on services is below budget, then the providers may share in Medicare savings; alternatively, if providers’ costs exceed the budget, then the providers may incur losses.”

BPCI Advanced, which began in October and is scheduled to run through 2023, builds on BPCI. It features simplified requirements that, as Becker’s Hospital CFO Report notes, increase “risk for [provider] participants while reducing flexibility… It remains to be seen how attractive this more standardized program will be to providers.” In fact, Amol Navathe and colleagues, writing for Health Affairs, critique BPCI Advanced for failing to create physician-focused payment models.

On the other hand, as Today’s Hospitalist reports, BPCI Advanced “qualifies as an advanced alternative payment model under MACRA. That means that participants are potentially eligible for alternative-payment bonuses” (although meeting the annual threshold of Medicare patients required to qualify for those bonuses may prove difficult). In addition, BPCI Advanced takes patient case-mix into account “by risk adjusting the target price [and] the benchmark price against which costs are measured,” as Health Affairs explains.

BPCI Advanced adds three outpatient episodes to the 29 inpatient episodes already offered in BPCI, thus alleviating some concerns about BPCI having been too focused on the hospital setting. These first-ever bundled outpatient episodes are:

  1. Percutaneous Coronary Intervention (PCI) – a nonsurgical procedure, sometimes called coronary angioplasty, to open narrowed or blocked coronary arteries and improve blood flow to the heart.
  2. Cardiac Defibrillator (CD) – Specifically, an implanted CD to control irregular heartbeats, especially those that can cause sudden cardiac arrest.
  3. Back and Neck Surgical Procedures (except Spinal Fusion) –  Cervical and non-cervical as well as combined anterior posterior spinal fusion procedures are included among the inpatient episodes.

According to CMS Administrator Seema Verma, BPCI Advanced marks “an important step in the move away from fee-for-service… Under this model, providers will have an incentive to deliver efficient, high-quality care.”

Questions about whether and how well the newest bundled payment program will achieve these goals remain. For example, can it help reduce readmission rates for certain conditions such as liver disorders, which already see an over 40% rate under BPCI? But 1299 BPCI Advanced participants are in place, set to test whether the model improves patient outcomes while cutting Medicare spending.


How do CMS Bundled Payment Programs Affect Medical Coding?

Some experts worry about the increased use of bundled payments. They suspect it may motivate unscrupulous practitioners to steer clear of “sick” patients whose care costs more, postpone coding complications that raise the cost of care, or upcode patient care in order to receive bigger payments. “Under any reimbursement model,” Dr. Terry Shih and colleagues write in the journal Circulation, “there are always ways to ‘game’ the system, and bundled payments are no different.”

Apart from these concerns, BCPI Advanced highlights the need to change current CPT® coding and billing guidelines. In 2013, Dr. Darrell Kirch, president of the Association of American Medical Colleges, wrote to the Senate Finance Committee about Medicare physician payment reform. Among other topics, he addressed the assumptions underpinning current CMS regulations: “The documentation requirements must change from supporting billing that is based
on individual level of effort (the current evaluation and management system) to supporting payment for care that is provided by a team and is expected to meet metrics related to quality and cost.”

But until such reform happens, what do ethical, responsible providers like you need to know about coding for bundled payments?

  • Communicate with other providers.
    CMS’ bundled payment programs are designed to discourage fragmentary care with minimal coordination in favor of true continuity of care. It’s vital, therefore, that you establish and maintain open channels of communication with other providers. This is especially true with providers of rehabilitative services, as many patients need these post-acute care. You’ll ensure your patients are receiving quality care, you’ll learn from colleagues, and you’ll pave the way for smooth gainsharing.
  • Make coding education a priority.
    View reimbursement changes as an opportunity to learn. As health information management expert Laurie McBrierty writes for ICD10 Monitor, “The clock is ticking on your preparedness… Educate yourself now so your organization will be optimally prepared.” It never hurts to brush up on or master for the first time basic coding and billing guidelines—especially CMS bundled codes already in use, such as transitional care codes.
  • Refine your documentation practices.
    The more you learn about medical coding, the more you realize how critical accurate and thorough documentation really is. It will continue to be vital to your success with bundled payment programs. The code selections included in the bundle must properly reflect a patient’s condition and all aspects of his or her treatment. Bundled payments, Dari Bonner writes for AHIMA, “incentivize efficient and effective care, requiring physicians to document as specifically and completely as possible.”


Code Confidently in the Midst of Change with MDCodePro

Although CMS bundled payment programs are changing, certain elements of the coding, billing, and payment process won’t change, such as the crucial importance of strong documentation and the centrality of a complexity risk score in determining medical necessity.

When you correctly use the MDCodePro methodology — which has been validated in multiple audits — to document patient visits, you’re ensuring your notes and charts will always contain enough information to support the highest appropriate CPT® code. You’ll have peace of mind knowing your records are accurate and comprehensive, are in compliance with CMS guidelines, and capture the most revenue (whether part of a bundled payment or not) to which you’re entitled for your services.

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