Bundled Payments for Care Improvement (BPCI) Initiative: General Information

On January 31, 2013, the Centers for Medicare & Medicaid Services (CMS) announced the health care organizations selected to participate in  the Bundled Payments for Care Improvement initiative, an innovative new payment model. Under the Bundled Payments for Care Improvement initiative, organizations will enter into payment arrangements that include financial and performance accountability for episodes of care. These models may lead to higher quality, more coordinated care at a lower cost to Medicare.

BPCI All Models mapped

Background

Traditionally, Medicare makes separate payments to providers for each of the individual services they furnish to beneficiaries for a single illness or course of treatment. This approach can result in fragmented care with minimal coordination across providers and health care settings. Payment rewards the quantity of services offered by providers rather than the quality of care furnished. Research has shown that bundled payments can align incentives for providers – hospitals, post-acute care providers, physicians, and other practitioners– allowing them to work closely together across all specialties and settings.

The 4 Models

The Bundled Payments initiative is comprised of four broadly defined models of care, which link payments for multiple services beneficiaries receive during an episode of care. Model 1 includes an episode of care focused on the acute care inpatient hospitalization. Awardees agree to provide a standard discount to Medicare from the usual Part A hospital inpatient payments.

Models 2 and 3 involve a retrospective bundled payment arrangement where actual expenditures are reconciled against a target price for an episode of care. Model 4 involves a prospective bundled payment arrangement, where a lump sum payment is made to a provider for the entire episode of care. Over the course of the three-year initiative, CMS will work with participating organizations to assess whether the models being tested result in improved patient care and lower costs to Medicare.

 

Model 1: Retrospective Acute Care Hospital Stay Only

Under Model 1, the episode of care is defined as the inpatient stay in the acute care hospital. Medicare will pay the hospital a discounted amount based on the payment rates established under the Inpatient Prospective Payment System used in the original Medicare program. Medicare will continue to pay physicians separately for their services under the Medicare Physician Fee Schedule. Under certain circumstances, hospitals and physicians will be permitted to share gains arising from the providers’ care redesign efforts. Participation will begin as early as April, 2013 and no later than January, 2014 and will include most Medicare fee-for-service discharges for the participating hospitals.

 

Model 2: Retrospective Acute Care Hospital Stay plus Post-Acute Care

In Model 2, the episode of care will include the inpatient stay in the acute care hospital and all related services during the episode. The episode will end either 30, 60, or 90 days after hospital discharge. Participants can select up to 48 different clinical condition episodes.

 

Model 3: Retrospective Post-Acute Care Only

For Model 3, the episode of care will be triggered by an acute care hospital stay and will begin at initiation of post-acute care services with a participating skilled nursing facility, inpatient rehabilitation facility, long-term care hospital or home health agency. The post-acute care services included in the episode must begin within 30 days of discharge from the inpatient stay and will end either a minimum of 30, 60, or 90 days after the initiation of the episode. Participants can select up to 48 different clinical condition episodes.

 

Model 4: Acute Care Hospital Stay Only

Under Model 4, CMS will make a single, prospectively determined bundled payment to the hospital that would encompass all services furnished during the inpatient stay by the hospital, physicians, and other practitioners. Physicians and other practitioners will submit “no-pay” claims to Medicare and will be paid by the hospital out of the bundled payment. Related readmissions for 30 days after hospital discharge will be included in the bundled payment amount. Participants can select up to 48 different clinical condition episodes.

Episodes of Care

Under the Bundled Payments for Care Improvement initiative, organizations will enter into payment arrangements that include financial and performance accountability for episodes of care. These models may lead to higher quality, more coordinated care at a lower cost to Medicare. 

Click "Read More" below to see the DRGs that are included in each episode. There are 48 episodes that participants were able to choose from. See details on the health care facilities and the episodes they will be testing.

 

Major joint upper extremity
483 Major joint and limb reattachment procedure of upper extremity with complication or comorbidity or major complication or comorbidity
484 Major joint and limb reattachment procedure of upper extremity without complication or comorbidity or major complication or comorbidity

Amputation
239 Amputation for circulatory system disorder except upper limb and toe with major complication or comorbidity
240 Amputation for circulatory system disorder except upper limb and toe with complication or comorbidity
241 Amputation for circulatory system disorder except upper limb and toe without complication or comorbidity or major complication or comorbidity
255 Upper limb and toe amputation for circulatory system disorder with major complication or comorbidity
256 Upper limb and toe amputation for circulatory system disorder with complication or comorbidity
257 Upper limb and toe amputation for circulatory system disorder without complication or comorbidity or major complication or comorbidity
474 Amputation for musculoskeletal system and connective tissue disease with major complication or comorbidity
475 Amputation for musculoskeletal system and connective tissue disease with complication or comorbidity
476 Amputation for musculoskeletal system and connective tissue disease without complication or comorbidity or major complication or comorbidity
616 Amputation of lower limb for endocrine,nutritional,and metabolic disease with major complication or comorbidity
617 Amputation of lower limb for endocrine,nutritional,and metabolic disease withcomplication or comorbidity
618 Amputation of lower limb for endocrine,nutritional,and metabolic disease without complication or comorbidity or major complication or comorbidity

Urinary tract infection
689 Kidney and urinary tract infections with major complication or comorbidity
690 Kidney and urinary tract infections without major complication or comorbidity

Stroke
61 Acute ischemic stroke with use of thrombolytic agent with major complication or comorbidity
62 Acute ischemic stroke with use of thrombolytic agent with complication or comorbidity
63 Acute ischemic stroke with use of thrombolytic agent without complication or comorbidity or major complication or comorbidity
64 Intracranial hemorrhage or cerebral infarction with major complication or comorbidity
65 Intracranial hemorrhage or cerebral infarction with complication or comorbidity or tPA in 24 hours
66 Intracranial hemorrhage or cerebral infarction without complication or comorbidity or major complication or comorbidity

Chronic obstructive pulmonary disease, bronchitis/asthmae
190 Chronic obstructive pulmonary disease with major complication or comorbidity
191 Chronic obstructive pulmonary disease with complication or comorbidity
192 Chronic obstructive pulmonary disease without complication or comorbidity or major complication or comorbidity
202 Bronchitis and asthma with complication or comorbidity or and major complication or comorbidity
203 Bronchitis and asthma without complication or comorbidity or major complication or comorbidity

Coronary artery bypass graft surgery
231 Coronary bypass with percutaneous transluminal coronary angioplasty with major complication or comorbidity
232 Coronary bypass with percutaneous transluminal coronary angioplasty without major complication or comorbidity
233 Coronary bypass with cardiac catheterization with major complication or comorbidity
234 Coronary bypass with cardiac cathetererization without major complication or comorbidity
235 Coronary bypass without cardiac catheterization with major complication or comorbidity
236 Coronary bypass without cardiac catheterization without major complication or comorbidity

Major joint replacement of the lower extremity
469 Major joint replacement or reattachment of lower extremity with major complication or comorbidity
470 Major joint replacement or reattachment of lower extremity without major complication or comorbidity

Percutaneous coronary intervention
246 Percutaneous cardiovascular procedure with drug-eluting stent with major complication or comorbidity
247 Percutaneous cardiovascular procedure with drug-eluting stent without major complication or comorbidity
248 Percutaneous cardiovascular procedure with non-drug-eluting stent with major complication or comorbidity
249 Percutaneous cardiovascular procedure with non-drug-eluting stent without major complication or comorbidity
250 Percutaneous cardiovascular procedure without coronary artery stent with major complication or comorbidity
251 Percutaneous cardiovascular procedure without coronary artery stent without major complication or comorbidity

Pacemaker
242 Permanent cardiac pacemaker implant with major complication or comorbidity
243 Permanent cardiac pacemaker implant with complication or comorbidity
244 Permanent cardiac pacemaker implant without complication or comorbidity or major complication or comorbidity

Cardiac defibrillator
222 Cardiac defibrillator implant with cardiac catheterization with acute myocardial infarction/heart failure/shock with major complication or comorbidity
223 Cardiac defibrillator implant with cardiac catheterization with acute myocardial infarction/heart failure/shock without major complication or comorbidity
224 Cardiac defibrillator implant with cardiac catheterization without acute myocardial infarction/heart failure/shock with major complication or comorbidity
225 Cardiac defibrillator implant with cardiac catheterization without acute myocardial infarction/heart failure/shock without major complication or comorbidity
226 Cardiac defibrillator implant without cardiac catheterization with major complication or comorbidity
227 Cardiac defibrillator implant without cardiac catheterization without major complication or comorbidity

Pacemaker Device replacement or revision
258 Cardiac pacemaker device replacement with major complication or comorbidity
259 Cardiac pacemaker device replacement without major complication or comorbidity
260 Cardiac pacemaker revision except device replacement with major complication or comorbidity
261 Cardiac pacemaker revision except device replacement with complication or comorbidity
262 Cardiac pacemaker revision except device replacement without complication or comorbidity or major complication or comorbidity

Automatic implantable cardiac defibrillator generator or lead
245 Automatic implantable cardioverter defibrillator generator procedures
265 Automatic implantable cardioverter defibrillator lead procedures

Congestive heart failure
291 Heart failure and shock with major complication or comorbidity
292 Heart failure and shock with complication or comorbidity
293 Heart failure and shock without complication or comorbidity or major complication or comorbidity

Acute myocardial infarction
280 Acute myocardial infarction, disease/discharged alive with major complication or comorbidity
281 Acute myocardial infarction, disease/discharged alive with complication or comorbidity
282 Acute myocardial infarction, disease/discharged alive without complication or comorbidity or major complication or comorbidity

Cardiac arrhythmia
308 Cardiac arrhythmia and conduction disorders with major complication or comorbidity
309 Cardiac arrhythmia and conduction disorders with complication or comorbidity
310 Cardiac arrhythmia and conduction disorders without complication or comorbidity or major complication or comorbidity

Cardiac valve
216 Cardiac valve and other major cardiothoracic procedure with cardiac catheterization with major complication or comorbidity
217 Cardiac valve and other major cardiothoracic procedure with cardiac catheterization with complication or comorbidity
218 Cardiac valve and other major cardiothoracic procedure with card catheter without complication or comorbidity and major complication or comorbidity
219 Cardiac valve and other major cardiothoracic procedure without cardiac catheterization with major complication or comorbidity
220 Cardiac valve and other major cardiothoracic procedure without cardiac catheterization with complication or comorbidity
221 Cardiac valve and other major cardiothoracic procedure without cardiac cathetererization without complication or comorbidity or major complication or comorbidity

Other vascular surgery
252 Other vascular procedures with major complication or comorbidity
253 Other vascular procedures with complication or comorbidity
254 Other vascular procedures without complication or comorbidity or major complication or comorbidity

Major cardiovascular procedure
237 Major cardiovascular procedures with major complication or comorbidity
238 Major cardiovascular procedures without major complication or comorbidity

Gastrointestinal hemorrhage
377 Gastrointestinal hemorrhage with major complication or comorbidity
378 Gastrointestinal hemorrhage with complication or comorbidity
379 Gastrointestinal hemorrhage without complication or comorbidity or major complication or comorbidity

Major bowel
329 Major small and large bowel procedures with major complication or comorbidity
330 Major small and large bowel procedures with complication or comorbidity
331 Major small and large bowel procedures without complication or comorbidity or major complication or comorbidity

Fractures femur and hip/pelvis
533 Fractures of femur with major complication or comorbidity
534 Fractures of femur without major complication or comorbidity
535 Fractures of hip and pelvis with major complication or comorbidity
536 Fractures of hip and pelvis without major complication or comorbidity

Medical non-infectious orthopedic
537 Sprains, strains, and dislocations of hip, pelvis and thigh with complication or comorbidity or major complication or comorbidity
538 Sprains, strains, and dislocations of hip, pelvis and thigh without complication or comorbidity or major complication or comorbidity
551 Medical back problems with major complication or comorbidity
552 Medical back problems without major complication or comorbidity
553 Bone diseases and arthropathies with major complication or comorbidity
554 Bone diseases and arthropathies without major complication or comorbidity
555 Signs and symptoms of musculoskeletal system and connective tissue with major complication or comorbidity
556 Signs and symptoms of musculoskeletal system and connective tissue without major complication or comorbidity
557 Tendonitis, myositis and bursitis with major complication or comorbidity
558 Tendonitis, myositis and bursitis without major complication or comorbidity
559 Aftercare, musculoskeletal system and connective tissue with major complication or comorbidity
560 Aftercare, musculoskeletal system and connective tissue with complication or comorbidity
561 Aftercare, musculoskeletal system and connective tissue without complication or comorbidity or major complication or comorbidity
562 Fracture, sprain, strain and dislocation except femur, hip, pelvis and thigh with major complication or comorbidity
563 Fracture, sprais, strain and dislcation except femur, hip, pelvis and thigh without major complication or comorbidity

Double joint replacement of the lower extremity
461 Bilateral or multiple major joint procedures of lower extremity with major complication or comorbidity
462 Bilateral or multiple major joint procedures of lower extremity without major complication or comorbidity

Revision of the hip or knee
466 Revision of hip or knee replacement with major complication or comorbidity
467 Revision of hip or knee replacement with complication or comorbidity
468 Revision of hip or knee replacement without complication or comorbidity oe major complication or comorbidity

Spinal fusion (non-Cervical)
459 Spinal fusion except cervical with major complication or comorbidity
460 Spinal fusion except cervical without major complication or comorbidity

Hip and femur procedures except major joint
480 Hip and femur procedures except major joint with major complication or comorbidity
481 Hip and femur procedures except major joint with complication or comorbidity
482 Hip and femur procedures except major joint without complication or comorbidity or major complication or comorbidity

Cervical spinal fusion
471 Cervical spinal fusion with major complication or comorbidity
472 Cervical spinal fusion with complication or comorbidity
473 Cervical spinal fusion without complication or comorbidity or major complication or comorbidity

Other knee procedures
485 Knee procedures with primary diagnosis of infection with major complication or comorbidity
486 Knee procedures with primary diagnosis of infection with complication or comorbidity
487 Knee procedures with primary diagnosis of infection without complication or comorbidity or major complication or comorbidity
488 Knee procedures without primary diagnosis of infection with complication or comorbidity or major complication or comorbidity
489 Knee procedures without primary diagnosis of infection without complication or comorbidity or major complication or comorbidity

Complex non-Cervical spinal fusion
456 Spinal fusion except cervical with spinal curvature/malignancy/infection or 9+ fusions with major complication or comorbidity
457 Spinal fusion except cervical with spinal curvature/malignancy/infection or 9+ fusions with complication or comorbidity
458 Spinal fusion except cervical with spinal curvature/malignancy/infection or 9+ fusions without complication or comorbidity or major complication or comorbidity

Combined anterior posterior spinal fusion
453 Combined anterior/posterior spinal fusion with major complication or comorbidity
454 Combined anterior/posterior spinal fusion with complication or comorbidity
455 Combined anterior/posterior spinal fusion without complication or comorbidity or major complication or comorbidity

Back and neck except spinal fusion
490 Back and neck procedures except spinal fusion with complication or comorbidity or major complication or comorbidiy or disc device/neurostimulator
491 Back and neck procedures except spinal fusion without complication or comorbidity or major complication or comorbidity

Lower extremity and humerus procedure except hip, foot, femur
492 Lower extremity and humerus procedures except hip,foot,femur with major complication or comorbidity
493 Lower extremity and humerus procedures except hip,foot,femur with complication or comorbidity
494 Lower extremity and humeusr procedurse except hip,foot,femur without complication or comorbidity or major complication or comorbidity

Removal of orthopedic devices
495 Local excision and removal internal fixation devices except hip and femur with major complication or comorbidity
496 Local excision and removal internal fixation devices except hip and femur with complication or comorbidity
497 Local excision and removal internal fixation devices except hip and femur without complication or comorbidity or major complication or comorbidity
498 Local excision and removal internal fixation devices of hip and femur with complication or comorbidity or major complication or comorbidity
499 Local excision and removal internal fixation devices of hip and femur without complication or comorbidity or major complication or comorbidity

Sepsis
870 Septicemia or severe sepsis with mechanical ventilation 96+ hours
871 Septicemia or severe sepsis without mechanical ventilation 96+ hours with major complication or comorbidity
872 Septicemia or severe sepsis without mechanical ventilation 96+ hours without major complication or comorbidity

Diabetes
637 Diabetes with major complication or comorbidity
638 Diabetes with complication or comorbidity
639 Diabetes without complication or comorbidity or major complication or comorbidity

Simple pneumonia and respiratory infections
177 Respiratory infections and inflammations with major complication or comorbidity
178 Respiratory infections and inflammations with complication or comorbidity
179 Respiratory infections and inflammations without complication or comorbidity or major complication or comorbidity
193 Simple pneumonia and pleurisy with major complication or comorbidity
194 Simple pneumonia and pleurisy with complication or comorbidity
195 Simple pneumonia and pleurisy without complication or comorbidity or major complication or comorbidity

Other respiratory
189 Pulmonary edema and respiratory failure
204 Respiratory signs and symptoms
205 Other respiratory system diagnoses with major complication or comorbidity
206 Other respiratory system diagnoses without major complication or comorbidity
207 Respiratory system diagnosis with ventilator support 96+ hours
208 Respiratory system diagnosis with ventilator support <96 hours
186 Pleural effusion with major complication or comorbidity
187 Pleural effusion with complication or comorbidity
188 Pleural effusion without complication or comorbidity or major complication or comorbidity

Chest pain
313 Chest pain

Medical peripheral vascular disorders
299 Peripheral vascular disorders with major complication or comorbidity
300 Peripheral vascular disorders with complication or comorbidity
301 Peripheral vascular disorders without complication or comorbidity or major complication or comorbidity

Atherosclerosis
302 Atherosclerosis with major complication or comorbidity
303 Atherosclerosis without major complication or comorbidity

Gastrointestinal obstruction
388 Gastrointestinal obstruction with major complication or comorbidity
389 Gastrointestinal obstruction with complication or comorbidity
390 Gastrointestinal obstruction without complication or comorbidity or major complication or comorbidity

Syncope and collapse
312 Syncope and collapse

Renal failure
682 Renal failure with major complication or comorbidity
683 Renal failure with complication or comorbidity
684 Renal failure without complication or comorbidity or major complication or comorbidity

Nutritional and metabolic disorders
640 Miscellabeous disorders of nutrition, metabolism, fluid/electrolytes with major complication or comorbidity
641 Miscellabeous disorders of nutrition, metabolism, fluid/electrolytes without major complication or comorbidity

Cellulitis
602 Cellulitis with major complication or comorbidity
603 Cellulitis without major complication or comorbidity

Red blood cell disorders
811 Red blood cell disorders with major complication or comorbidity
812 Red blood cell disorders without major complication or comorbidity

Transient ischemia
69 Transient ischemia

Esophagitis, gastroenteritis and other digestive disorders
391 Esophagitis, gastroenteritis and miscellaneous digestive disorders with major complication or comorbidity
392 Esophagitis, gastroenteritis and miscellaneous digestive disorders without major complication or comorbidity

 

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