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 that reward the quality, not the quantity, of services—value over volume. They 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, 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 Bundled Payments for Care Improvement Initiative (BPCI).

In 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 “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 builds on BPCI, featuring 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.”

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).

BPCI Advanced adds three outpatient episodes to the 29 inpatient episodes already offered in BPCI:

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.”

How do CMS Bundled Payment Programs Affect Medical Coding?

Some experts worry increased use of bundled payments will motivate unscrupulous practitioners to steer clear of “sick” patients whose care costs more, postpone coding complications that may raise the cost of care, or upcode patients to get larger payments. “Under any reimbursement model,” Dr. Terry Shih and colleagues write in the cardiovascular 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 responsible providers like you need to know about coding for bundled payments?

• Communicate with other providers.
  Because CMS’ bundled payment programs encourage continuity of care, it’s vital you establish and maintain open channels of communication with other providers (especially providers of rehabilitative services, as many patients need these after acute care). You’ll ensure your patients are receiving quality care, learn from colleagues, and 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.” Plus, it never hurts to brush up on or master for the first time the basics of the 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 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.

You can rely on MDCodePro to both educate you about the fundamentals of medical coding and help you code your services for maximum accuracy, regulatory compliance, and revenue.

Ready to find out more? Please contact us online using this form.

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