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.
Amputation expand icon Read More
Urinary tract infection expand icon Read More
Stroke expand icon Read More
Chronic obstructive pulmonary disease, bronchitis/asthmae expand icon Read More
Coronary artery bypass graft surgery expand icon Read More
Major joint replacement of the lower extremity expand icon Read More
Percutaneous coronary intervention expand icon Read More
Pacemaker expand icon Read More
Cardiac defibrillator expand icon Read More
Pacemaker Device replacement or revision expand icon Read More
Automatic implantable cardiac defibrillator generator or lead expand icon Read More
Congestive heart failure expand icon Read More
Acute myocardial infarction expand icon Read More
Cardiac arrhythmia expand icon Read More
Cardiac valve expand icon Read More
Other vascular surgery expand icon Read More
Major cardiovascular procedure expand icon Read More
Gastrointestinal hemorrhage expand icon Read More
Major bowel expand icon Read More
Fractures femur and hip/pelvis expand icon Read More
Medical non-infectious orthopedic expand icon Read More
Double joint replacement of the lower extremity expand icon Read More
Revision of the hip or knee expand icon Read More
Spinal fusion (non-Cervical) expand icon Read More
Hip and femur procedures except major joint expand icon Read More
Cervical spinal fusion expand icon Read More
Other knee procedures expand icon Read More
Complex non-Cervical spinal fusion expand icon Read More
Combined anterior posterior spinal fusion expand icon Read More
Back and neck except spinal fusion expand icon Read More
Lower extremity and humerus procedure except hip, foot, femur expand icon Read More
Removal of orthopedic devices expand icon Read More
Sepsis expand icon Read More
Diabetes expand icon Read More
Simple pneumonia and respiratory infections expand icon Read More
Other respiratory expand icon Read More
Chest pain expand icon Read More
Medical peripheral vascular disorders expand icon Read More
Atherosclerosis expand icon Read More
Gastrointestinal obstruction expand icon Read More
Syncope and collapse expand icon Read More
Renal failure expand icon Read More
Nutritional and metabolic disorders expand icon Read More
Cellulitis expand icon Read More
Red blood cell disorders expand icon Read More
Transient ischemia expand icon Read More
Esophagitis, gastroenteritis and other digestive disorders expand icon Read More
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 expand icon Read More
| 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 |
| 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 |
| 689 | Kidney and urinary tract infections with major complication or comorbidity |
| 690 | Kidney and urinary tract infections without major complication or comorbidity |
| 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 |
| 66 | Intracranial hemorrhage or cerebral infarction without complication or comorbidity or major complication or comorbidity |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 245 | Automatic implantable cardioverter defibrillator generator procedures |
| 265 | Automatic implantable cardioverter defibrillator lead procedures |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 237 | Major cardiovascular procedures with major complication or comorbidity |
| 238 | Major cardiovascular procedures without major complication or comorbidity |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 459 | Spinal fusion except cervical with major complication or comorbidity |
| 460 | Spinal fusion except cervical without major complication or comorbidity |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 637 | Diabetes with major complication or comorbidity |
| 638 | Diabetes with complication or comorbidity |
| 639 | Diabetes without complication or comorbidity or major complication or comorbidity |
| 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 |
| 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 |
| 313 | Chest pain |
| 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 |
| 302 | Atherosclerosis with major complication or comorbidity |
| 303 | Atherosclerosis without major complication or comorbidity |
| 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 |
| 312 | Syncope and collapse |
| 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 |
| 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 |
| 602 | Cellulitis with major complication or comorbidity |
| 603 | Cellulitis without major complication or comorbidity |
| 811 | Red blood cell disorders with major complication or comorbidity |
| 812 | Red blood cell disorders without major complication or comorbidity |
| 69 | Transient ischemia |
| 391 | Esophagitis, gastroenteritis and miscellaneous digestive disorders with major complication or comorbidity |
| 392 | Esophagitis, gastroenteritis and miscellaneous digestive disorders without major complication or comorbidity |
Additional Information
