The Context of Coding and Bundled Payment

Bundled payment (also known as episode-based payment, episode-of-care payment, and global bundled payment) is likely to be a feature of the American medical landscape. Although similar to MS-DRG related reimbursement, bundled payment goes further in its all-encompassing nature. The full episode of care across providers and facilities is bundled into one reimbursement. Add to this mix the transition to ICD-10, and it's no wonder that the tracking and reimbursement of bundled care services prove to be a challenge.

If your health care organization participates in a bundled payment initiative, it is crucial that your coders be familiar with the codes that are part of the bundled payment protocol. Given its prevalence, expense and the breadth of care required, a joint replacement procedure identifies as an ideal model for bundled payment.

The Centers for Medicare and Medicaid Services (CMS) initiated the Comprehensive Care for Joint Replacement Model (CJR) in November 2016. The appropriate use of MS-DRGs 469 and 470 served as key indicators in the identification of patient participants in this model. Clearly coding matters at this initial entry point as different target prices are determined by which MS-DRG is specified.

How does a coder navigate the complexity and context required within the bundled payment initiative? Here are some suggestions.

1.  Develop expertise in the bundled care initiatives already within the ICD-10 CM/PCS arena. A solid understanding of the nuances of diagnostic and procedural codes provides a firmer foundation in coding for episode-of-care.

2.  Establish good communication with contacts at outpatient provider offices. Bundled payment encompasses continuity of care. Relationship building serves as a key component, as a patient receives treatment modalities in varying settings.   

3.  Do not underestimate the importance of post-acute care. Rehabilitative services remain a reality for many patients with a diagnosis that will be reimbursed under bundled payment. It is particularly helpful to have good relationships with personnel at these facilities.

4.  Make clinical documentation improvement (CDI) a priority. This area consistently provides ongoing growth opportunity. With the implementation of ICD-10, further provider education should focus on the various code selections included in the bundled payment initiatives to ensure that the complete clinical picture is documented. It is also imperative to help the provider understand the importance of communicating in a timely and informative manner with the coding staff. The essence of CDI is translating a clinical diagnosis into a numerical code. Both skill sets prove invaluable in creating an accurate depiction of the severity of a patient’s condition, along with all aspects of their treatment.

5.  Education and training are well worth the investment, time and effort to increase productivity. Coding accurately and efficiently on a daily basis is a demanding job. Throw in the vicissitudes of health care regulation, reimbursement and reform, and it’s obvious that seeking professional training is a smart move.

As with every other change that has arisen in health care administration, bundled payment affects the overall revenue cycle. Learn how to meet the challenge in this unchartered territory and to not only survive, but thrive.

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