Category: Clinical Documentation

CDI Services
Clinical Documentation

The Significance of Clinical Documentation Improvement (CDI) Services in Healthcare: Enhancing Outpatient and Inpatient Care

Sep 27, 2023 by Shankar R 0 Comments , ,

In today’s rapidly evolving healthcare landscape, the effective management of clinical documentation plays a pivotal role in providing high-quality patient care. Clinical Documentation Improvement (CDI) services have emerged as a vital component, ensuring that healthcare organizations deliver accurate, complete, and compliant medical records. In this blog, we’ll explore the significance of CDI services for both outpatient and inpatient care in the healthcare industry.

  1. Precision in Patient Care

In the realm of outpatient care, CDI services have a significant impact on ensuring precision in diagnoses and treatment plans. Accurate and comprehensive clinical documentation allows healthcare providers to make well-informed decisions, reducing the likelihood of misdiagnosis or incorrect treatment. When outpatient records are meticulously maintained, physicians can easily access a patient’s medical history, enabling them to tailor treatments and interventions to the individual’s specific needs.

  1. Enhanced Continuity of Care

For patients transitioning between outpatient and inpatient settings, the continuity of care is critical. CDI services bridge this gap by maintaining consistent, detailed records that follow patients across various healthcare settings. This ensures that healthcare providers have access to the patient’s complete medical history, enabling them to provide seamless and well-informed care. Whether a patient is receiving ongoing treatment for a chronic condition or facing an acute health issue requiring hospitalization, CDI services facilitate a smoother care transition.

  1. Regulatory Compliance and Reimbursement

Inpatient care involves complex billing and coding processes, where precision is essential to ensure proper reimbursement and compliance with regulatory standards. CDI services play a crucial role in ensuring that inpatient records adhere to coding guidelines and regulatory requirements. Accurate documentation can help healthcare organizations avoid costly audits, penalties, and denials, ultimately improving financial stability.

  1. Quality Improvement Initiatives

In the healthcare industry, quality improvement is an ongoing process aimed at enhancing patient outcomes. CDI services contribute significantly to this effort by identifying opportunities for improvement through detailed analysis of clinical documentation. By pinpointing areas where documentation can be enhanced, healthcare organizations can implement targeted quality improvement initiatives, leading to better patient care and improved overall performance.

  1. Efficient Resource Allocation

Efficiency is a cornerstone of healthcare delivery, and CDI services aid in optimizing resource allocation. By ensuring that clinical documentation accurately reflects the care provided, healthcare organizations can avoid unnecessary repetition of tests and procedures, reduce hospital readmissions, and optimize resource utilization. This not only enhances patient care but also contributes to cost savings in the long run.

  1. Data-Driven Decision Making

In an era where data drives healthcare decisions, CDI services provide a wealth of valuable information. By maintaining comprehensive patient records, healthcare organizations can leverage data analytics to identify trends, evaluate treatment effectiveness, and make informed decisions about resource allocation and care protocols.

In conclusion, Clinical Documentation Improvement (CDI) services are indispensable in today’s healthcare landscape, benefiting both outpatient and inpatient care. These services enhance precision in diagnoses and treatment plans, ensure continuity of care, facilitate regulatory compliance, support quality improvement initiatives, optimize resource allocation, and enable data-driven decision-making. By prioritizing CDI, healthcare organizations can deliver higher-quality care, improve financial stability, and ultimately enhance the overall patient experience. CDI services are not just about documentation; they are about improving healthcare outcomes and making a meaningful difference in the lives of patients.

The goal of Saince CDI services is to increase the quality of patient care through personalized attention and education. Our CDI team is comprised of expert consultants who possess strong clinical knowledge combined with certifications in CDI and medical coding. Our experienced CDI consultants can help you design, develop or maintain your clinical documentation improvement program while increasing hospital and physician group revenue and decreasing costs.

Outpatient CDI
Clinical Documentation

Optimizing Outpatient Clinical Documentation Improvement: Elevating the Quality of Patient Care Through Accurate and Comprehensive Documentation

Mar 29, 2023 by Shankar R 0 Comments

Clinical documentation improvement (CDI) has become a crucial component of the healthcare industry, and with the rise of outpatient care, it has become more important than ever before. However, the focus of CDI has largely been on hierarchical condition categories (HCCs) and risk adjustment, leaving other important aspects of outpatient CDI neglected. If you want a complete and successful outpatient CDI program, just reviewing patient charts for HCCs is not enough. You need a solution that addresses all aspects of outpatient CDI, and there’s no better solution on the market than Doc-U-Aide.

Outpatient CDI encompasses more than just HCCs and risk adjustment. Quality measures, problem list maintenance, coding integrity, and documentation quality are all critical aspects of outpatient CDI that need to be addressed for a successful program. Each of these components plays a significant role in ensuring that the care delivered to patients is both effective and efficient. Neglecting any one of these areas can have a detrimental impact on patient care and overall outcomes.

For example, quality measures are essential in tracking the effectiveness of care delivery. These measures help to ensure that patients are receiving the appropriate care, as determined by evidence-based guidelines. Without proper documentation of these measures, it can be difficult to assess whether patients are receiving the care they need. This can result in missed opportunities for interventions or unnecessary treatments.

In addition to quality measures, problem list maintenance is also critical. A patient’s problem list provides a snapshot of their health status and serves as a communication tool between providers. Accurate and up-to-date problem lists are essential to ensure that providers have a complete picture of a patient’s health status, allowing them to make informed decisions regarding care delivery. Without proper documentation of problem lists, providers may miss critical information, resulting in suboptimal care.

Coding integrity is another critical aspect of outpatient CDI. Accurate coding is essential to ensure appropriate reimbursement and prevent potential audit issues. Without proper documentation and coding, healthcare organizations may face financial penalties or loss of revenue. Additionally, inaccurate coding can result in denials or delays in payment, which can impact the financial health of a healthcare organization.

Finally, documentation quality is essential to ensure that patient care is well-documented and can be effectively communicated between providers. Proper documentation not only supports accurate coding and billing, but also helps to ensure that providers have a complete understanding of a patient’s health status. This, in turn, can lead to improved care delivery and better patient outcomes.

While HCCs and risk adjustment are important components of outpatient CDI, they are not sufficient on their own. A complete and successful outpatient CDI program requires a solution that addresses all aspects of CDI, including quality measures, problem list maintenance, coding integrity, and documentation quality. And that solution is Doc-U-Aide.

Doc-U-Aide is the only solution on the market that provides a comprehensive approach to outpatient CDI. It combines artificial intelligence and natural language processing to deliver real-time feedback on documentation quality, ensuring that providers are capturing all necessary information. It also includes features to track quality measures, maintain problem lists, and ensure accurate coding, all in one easy-to-use platform.

In conclusion, if you want a complete and successful outpatient CDI program, just reviewing patient charts for HCCs is not enough. Quality measures, problem list maintenance, coding integrity, and documentation quality are all critical aspects that need to be addressed. And the best solution on the market to address all of these areas is Doc-U-Aide. Don’t neglect any aspect of outpatient CDI. Invest in a comprehensive solution today and ensure that your patients receive the best possible care.

Importance of Doc-U-Aide CDI Program
Clinical Documentation

Maximizing Healthcare Quality and Revenue: The Crucial Role of Doc-U-Aide CDI Program in Clinical Documentation Improvement

Mar 27, 2023 by Shankar R 0 Comments

In the healthcare industry, clinical documentation plays a critical role in ensuring quality patient care, accurate reimbursement, and compliance with regulatory requirements. To optimize clinical documentation, healthcare organizations must invest in clinical documentation improvement (CDI) programs. However, simply having a CDI program is not enough to ensure success. Without access to real-time data and analytics, CDI departments may struggle to identify areas for improvement and measure the impact of their efforts.

This is where Doc-U-Aide, our outpatient clinical documentation improvement solution, comes in. Doc-U-Aide provides over 30 on-demand reports, which no other competing solution provides. These reports offer crucial insights into the performance of the CDI program and enable CDI professionals to identify opportunities for improvement, monitor trends, and measure the impact of their efforts.

The importance of having these reports cannot be overstated. Without them, CDI professionals are essentially operating in the dark. They have no visibility into the performance of their program, making it difficult to identify areas for improvement and measure the effectiveness of their efforts. This can lead to missed opportunities to optimize clinical documentation, resulting in reduced reimbursement, increased denials, and compliance risks.

For example, imagine a CDI program that focuses on improving the accuracy of clinical documentation related to chronic conditions. Without access to real-time data and analytics, the CDI professionals may not realize that their efforts are not making a significant impact. They may be capturing more details about the patient’s condition, but these details may not be improving the accuracy of the documentation. With Doc-U-Aide’s on-demand reports, the CDI professionals could identify this issue and adjust their strategy accordingly.

In addition to identifying areas for improvement, Doc-U-Aide’s reports also enable CDI professionals to monitor trends and track their progress over time. This is critical for demonstrating the impact of the CDI program to stakeholders and ensuring ongoing support and funding. For example, if a CDI program focuses on reducing documentation errors related to E/M coding, they could use Doc-U-Aide’s reports to track their progress over several months. They could then demonstrate to leadership how their efforts have led to a reduction in denials and increased revenue.

Another benefit of having access to real-time data and analytics is the ability to respond quickly to changes in the healthcare landscape. For example, if a new regulatory requirement is introduced, CDI professionals can use Doc-U-Aide’s reports to quickly identify gaps in their documentation practices and adjust their strategy accordingly.

In summary, having access to real-time data and analytics is critical for the success of any CDI program. Without it, CDI professionals are essentially operating blind, with no visibility into the performance of their program. Doc-U-Aide’s on-demand reports provide over 30 critical insights into the performance of the CDI program, enabling CDI professionals to identify areas for improvement, monitor trends, and measure the impact of their efforts. Investing in Doc-U-Aide is not just an investment in a CDI solution, it’s an investment in the success of your CDI program and the quality of patient care.

Clinical Documentation, Clinical Documentation Improvement, Healthcare

Maximizing Inpatient Reimbursement and Quality of Care with Innovative CDI Solutions: A Comprehensive Approach

Mar 20, 2023 by Raghu Vir 0 Comments

Clinical Documentation Improvement (CDI) solutions and services are essential for ensuring that clinical documentation is accurate, complete, and specific. Inpatient CDI services focus on improving documentation for patients who are admitted to a hospital or other inpatient facility. In this article, we’ll explore the benefits of inpatient CDI solutions and services, and how they can improve patient care.

One of the primary benefits of inpatient CDI solutions and services is that they can help improve the accuracy and completeness of clinical documentation. This can have a significant impact on patient care, as accurate documentation can help ensure that patients receive appropriate treatment and monitoring. In addition, accurate documentation can help reduce the risk of errors and omissions, which can lead to incorrect diagnoses, treatment plans, and medication orders.

Another benefit of inpatient CDI solutions and services is that they can help improve coding and billing accuracy. Accurate coding is essential for proper reimbursement and can help ensure that healthcare providers are fairly compensated for the care they provide. By improving documentation, inpatient CDI solutions and services can help ensure that the correct codes are assigned to each patient encounter, which can reduce the risk of denials and appeals.

Inpatient CDI solutions and services can also help improve patient outcomes. By improving the quality of clinical documentation, healthcare providers can more accurately diagnose and treat patients, which can lead to better outcomes. For example, if a patient is admitted to the hospital with pneumonia, but the clinical documentation only mentions respiratory distress, the care team may not realize the severity of the patient’s condition. However, if the documentation is accurate and specific, the care team can provide appropriate treatment and monitor the patient closely to ensure they are recovering.

In addition to improving patient care and reimbursement, inpatient CDI solutions and services can also help healthcare organizations comply with regulatory requirements. For example, the Centers for Medicare & Medicaid Services (CMS) require hospitals to report quality measures, which are based on clinical documentation. Accurate and complete documentation is essential for compliance with these requirements, as well as other regulatory standards.

One key feature of inpatient CDI solutions and services is the use of technology to improve the CDI process. For example, natural language processing (NLP) can be used to analyze clinical documentation and identify areas where documentation can be improved. This can help streamline the CDI process and improve the accuracy of clinical documentation.

Inpatient CDI solutions and services can also provide education and training to healthcare providers. This can help providers understand the importance of clinical documentation and how to improve their documentation practices. By providing education and training, inpatient CDI solutions and services can help ensure that providers are equipped with the knowledge and skills they need to provide high-quality care and documentation.

Overall, inpatient CDI solutions and services offer a range of benefits to healthcare providers, patients, and healthcare organizations. By improving the accuracy and completeness of clinical documentation, improving coding and billing accuracy, improving patient outcomes, and supporting regulatory compliance, inpatient CDI solutions and services can help improve the overall quality of healthcare delivery. As healthcare continues to evolve, it’s likely that inpatient CDI solutions and services will become an increasingly important component of healthcare delivery, helping to support healthcare providers in providing the best possible care to their patients.

Clinical Documentation, Healthcare

Enhancing Clinical Documentation through Comprehensive CDI Services: Improving Patient Care and Reimbursement Accuracy

Mar 20, 2023 by Raghu Vir 0 Comments

Clinical Documentation Improvement (CDI) Services are an essential component of the healthcare industry, aimed at improving the accuracy, completeness, and specificity of clinical documentation. The goal of CDI Services is to ensure that healthcare providers have access to complete and accurate patient information, leading to better care, improved outcomes, and proper reimbursement. In this article, we will discuss the importance of CDI Services and how they can benefit healthcare organizations.

One of the primary benefits of CDI Services is improved patient care. Accurate and complete clinical documentation helps healthcare providers understand a patient’s medical history, diagnosis, and treatment plan, leading to better patient care. By improving the quality of clinical documentation, CDI Services can also help reduce the risk of medical errors, which can have significant consequences for patients. In addition, accurate documentation can help providers make more informed decisions about patient care, which can improve outcomes and reduce costs.

Another significant benefit of CDI Services is improved coding and billing accuracy. Proper coding is critical for proper reimbursement, and inaccurate coding can lead to denials and appeals, ultimately resulting in lost revenue. CDI Services can help ensure that accurate codes are assigned to each patient encounter, reducing the risk of denials and appeals and ensuring that healthcare providers are fairly compensated for the care they provide.

CDI Services can also help improve compliance with regulatory requirements. Healthcare providers are subject to numerous regulations and requirements, and accurate clinical documentation is essential for compliance. For example, healthcare organizations must comply with regulations such as the Health Insurance Portability and Accountability Act (HIPAA) and the Centers for Medicare & Medicaid Services (CMS) requirements. CDI Services can help ensure that healthcare providers are meeting these requirements, reducing the risk of penalties and fines.

In addition to improving patient care, coding and billing accuracy, and regulatory compliance, CDI Services can also provide significant financial benefits to healthcare organizations. By improving documentation, CDI Services can help healthcare providers identify areas where they can improve revenue cycle management, reduce denials, and increase reimbursement. In addition, accurate documentation can help healthcare organizations avoid costly litigation resulting from medical errors and omissions.

One of the key features of CDI Services is the use of technology to improve the CDI process. Natural Language Processing (NLP), machine learning, and other technologies can be used to analyze clinical documentation, identify areas where documentation can be improved, and automate parts of the CDI process. These tools can help streamline the CDI process, reduce the burden on healthcare providers, and improve the accuracy of clinical documentation.

CDI Services can also provide education and training to healthcare providers. This can help providers understand the importance of clinical documentation and how to improve their documentation practices. By providing education and training, CDI Services can help ensure that providers are equipped with the knowledge and skills they need to provide high-quality care and documentation.

Overall, CDI Services are an essential component of the healthcare industry, aimed at improving the accuracy, completeness, and specificity of clinical documentation. By improving patient care, coding and billing accuracy, regulatory compliance, and financial performance, CDI Services can help healthcare organizations provide better care to their patients, while also improving their bottom line. As healthcare continues to evolve, it’s likely that CDI Services will become an increasingly important component of healthcare delivery, helping to support healthcare providers in providing the best possible care to their patients.

The goal of the Saince CDI services is to increase the quality of patient care through personalized attention and education. Our CDI team is comprised of expert consultants who possess strong clinical knowledge combined with certifications in CDI and medical coding. Our experienced CDI consultants can help you design, develop or maintain your clinical documentation improvement program while increasing hospital and physician group revenue and decreasing costs. Contact us for more information.

Clinical Documentation, Healthcare

Is MIPS really doing what it is supposed to do? Research suggests that it is not.

Dec 8, 2022 by Raghu Vir 0 Comments , , ,

How well does the Merit-based Incentive Payment Program (MIPS) of Medicare measure the caliber of medical treatment that is given? According to the findings of a recent study, not very.

The 2017 introduction of MIPS, which replaced three prior quality measurement programs, aimed to enhance patient care by financially rewarding or penalizing physicians based on their performance on particular “process” and “outcome” metrics in four key areas: cost, quality, improvement activities, and fostering interoperability.

The six metrics that participating physicians choose to report on must include one outcome indicator, such as a hospital admission for a particular disease or condition. Currently, MIPS is the biggest value-based payment program in the country.

Data from Medicare statistics and claims records for 3.4 million individuals who saw about 80,000 primary care providers in 2019 were evaluated for the study by researchers. They compared doctors’ overall MIPS scores with their scores on five process measures, including breast cancer screening, tobacco screening, and diabetic eye exams, and six outcome measures, including ED visits and hospitalizations.

The findings showed there was no consistent relationship between the measures’ performance and the final MIPS ratings. For instance, doctors with low MIPS scores scored somewhat better on the other two process measures, while having much lower average MIPS scores than physicians with high MIPS scores on three of the five process measures examined.

Low-scoring doctors performed much worse on the all-cause hospitalizations per 1,000 patients metric than they did on the other four outcome measures, although they performed significantly better on the metric of ED visits per 1,000 patients. Similar to this, 21% of physicians with high MIPS scores had outcomes that were in the poorest percentile, compared to 19% of those with low MIPS scores who performed in the top quintile for composite outcomes performance.

The findings suggest that the MIPS program’s accuracy in identifying high- versus low-performing providers is really no better than chance.

For these findings, the authors provide a number of interpretations. Among them are the challenges in making meaningful comparisons when doctors are free to select the metrics they report on, the fact that many program metrics, as other research has shown, are either invalid or of dubious validity and thus may not be linked to better outcomes, and the possibility that high scores may simply be an indicator of a program’s capacity for data collection, analysis, and reporting rather than of higher quality medical care.

They claim that the latter conclusion is supported by the discovery that participants with low MIPS scores were more likely to work in independent, small practices even though their clinical outcomes were frequently comparable to those of medical professionals in large, system-affiliated practices with high MIPS scores.

This research was released in JAMA on December 6. https://jamanetwork.com/journals/jama/article-abstract/2799153

Clinical Documentation, Clinical Documentation Improvement, Outpatient CDI

Hospital Outpatient Departments: Effective July 1, 2020 you must request prior authorization for certain hospital Outpatient Department (OPD) services

Jun 25, 2020 by Raghu Vir 0 Comments

For dates of service beginning July 1, 2020, you must request prior authorization for the following hospital Outpatient Department (OPD) services:

  • Blepharoplasty
  • Botulinum toxin injections (when paired with specific procedure codes)
  • Panniculectomy
  • Rhinoplasty
  • Vein ablation

Medical necessity documentation requirements remain the same and hospital OPDs will receive a decision within 10 days.

While only the hospital OPD service requires prior authorization, CMS wants to remind other providers that perform services in the hospital OPD setting that claims related to/associated with these services will not be paid if the service requiring prior authorization is not eligible for payment. These related services include, but are not limited to, anesthesiology services, physician services, and facility services. Only associated services performed in the hospital OPD setting are affected. Depending on the timing of claim submission for any related services, claims may be automatically denied, reviewed, or denied on a postpayment basis.

For botulinum toxin injections, consult the list of codes that require prior authorization for more details. Generally, the use of botulinum toxin injection codes paired with procedure codes other than 64612 or 64615 will not require prior authorization under this program.

Artificial Intelligence, Clinical Documentation, Clinical Documentation Improvement, Dictation, EHR, EHR, Healthcare, Healthcare Technology, Morning musings from a CEO, Outpatient CDI, Radiology, Uncategorized

Saince announces the launch of tele-medicine feature within its clinical documentation solution

Jun 15, 2020 by Raghu Vir 0 Comments

Doc-U-Scribe clinical documentation solution now comes integrated with tele-medicine workflow. Physicians and administrators can create tele-consultation sessions with patients seamlessly from within the application. This process eliminates the need for providers to use separate solutions – one for clinical documentation and another for video session.

The COVID-19 public health crisis has accelerated the use of tele-medicine solutions among healthcare provides across the nation. However, many small hospitals and physician offices do not have access to a single solution that takes care of all their needs. Physicians are forced to use multiple solutions to complete their tele-medicine workflow. They are often finding this process frustrating and cumbersome.

Doc-U-Scribe clinical documentation solution which is used by hundreds of hospitals and physician offices across the country provides an integrated and seamless workflow for clinical documentation as well as tele-medicine.   This new HIPAA compliant tele-medicine solution can cut costs, increase efficiency, and improve physician satisfaction significantly.

Saince announced that this new feature will be available to all their existing customers immediately. Saince also announced that with their plug and play model, any new hospital or physician office can be up and running with their tele-medicine program within 48 hours.

Clinical Documentation

Safeguarding Cyber security Amid CDI Efforts

Dec 4, 2018 by admin 0 Comments

Original: Cyber security, Coding and CDI. Best practices to ensure best practices for cyber security are employed.

 

To say that the present state of healthcare cyber security poses a challenge for organizations undertaking clinical documentation improvement (CDI) efforts is a drastic understatement. Under the ever-present specter of costly cyber attacks, providers across the country continue to grapple with myriad, big-picture challenges such as information governance (IG), highly ambiguous government oversight and unstable compliance landscapes as well as shifting care settings.

 

Providers are required to adhere to strict security laws like HIPAA and HITECH while simultaneously acceding the regulatory demands of fluid information sharing contained in the 21st Century Cures Act—all while adapting to the logistical reality of increasingly frequent outpatient care delivery. Further intensifying those challenges, the shift to outpatient care means that greater volumes of protected health information (PHI) is being routed through ambulatory and other non-hospital settings, making them increasingly attractive targets for hackers. Additionally, a recent survey of medical coders also found that roughly one-third reported working remotely at some point, highlighting the potential vulnerability many providers face.

 

Healthcare Cyber Security

 

As they approach this challenging future, however, smart organizations can balance conflicting security and compliance concerns as well as inpatient and outpatient CDI initiatives by sharpening their focus in a few key areas.

 

Staffing and Training. In CDI, overwhelmed and under-trained teams are more apt to make costly mistakes. The same is true for cyber security. A misaligned and overworked team is a liability and leading cause of security breaches, but one with the tools, training and cohesion to efficiently manage their workflow is a powerful safeguard. The quickest way for any organization to promote quality and compliance—as well as security—while executing CDI efforts is to ensure its staff is trained well. Fostering alignment between providers, coding and other administrative staff must include education on common security risks, drills to identify weak points and emphasis on a culture where anomalies, breaches and prevention are openly discussed and addressed.

 

Emphasis on Accuracy and Clarity. Just as optimized CDI and streamlined organizational compliance—from the point of care to the submission of a claim—can reduce error-driven medical necessity denials, that same focus on accuracy and clarity can reduce security errors as well. As provider organizations seek to improve overall IG while also contending with growing troves of clinical data, enhanced CDI workflow is a necessary component strategy, intricately linked with all others.

 

Encryption of All Devices. Loss of mobile devices is a major cause of healthcare data breach, particularly in outpatient settings. As mobile devices become increasingly common tools in clinical documentation, ensuring that these devices and all computers are encrypted is an important, albeit not-HIPAA-required, step for organizations to take.

 

Vetting Vendors. An organization must safeguard its own internal protocols, but it must also ensure that its vendors—particularly those offering Software as a Service (Saas)—are taking all reasonable steps to protect data, confidentiality and security as well. It’s a must to understand a vendor’s risk assessments and require indemnification provisions and cyber security insurance in business associate agreements.

 

Designing your organization’s CDI efforts is a significant undertaking. To learn about  PracticePerfect, a platform to help you address outpatient CDI, or Doc-U-Aide, a revolutionary platform for inpatient CDI, contact Saince.

 

 

 

 

 

 

 

 

Clinical Documentation, EHR, Healthcare Technology

CMS introduces new payment model for both inpatient and outpatient care

Jan 10, 2018 by Raghu Vir 0 Comments

The Centers for Medicare & Medicaid Services (CMS) announced the launch of a new voluntary bundled payment model called Bundled Payments for Care Improvement Advanced (BPCI Advanced). Under traditional fee-for-service payment, Medicare pays providers for each individual service they perform. Under this bundled payment model, participants can earn additional payment if all expenditures for a beneficiary’s episode of care are under a spending target that factors in quality.

Bundled payments create incentives for providers and practitioners to work together to coordinate care and engage in continuous improvement to keep spending under a target amount. BPCI Advanced participants may receive payments for performance on 32 different clinical episodes which are listed below.

Of note, BPCI Advanced will qualify as an Advanced Alternative Payment Model (Advanced APM) under the Quality Payment Program (QPP). Under Advanced APMs, providers take on financial risk to earn the Advanced APM incentive payment.

BPCI Advanced will operate under a total-cost-of-care concept, in which the total Medicare fee for services (FFS) spending on all items and services furnished to a BPCI Advanced Beneficiary during the  Clinical Episode, including outlier payments, will be part of the Clinical Episode expenditures for purposes of the Target Price and reconciliation calculations, unless specifically excluded.

Clinical Episodes

BPCI Advanced will initially include 29 inpatient Clinical Episodes and 3 outpatient Clinical Episodes. Participants selected to participate in BPCI Advanced beginning on October 1, 2018, must commit to be held accountable for one or more Clinical Episodes and may not add or drop such Clinical Episodes until January 1, 2020.

Inpatient Clinical Episodes – 29

  • Disorders of the liver excluding malignancy, cirrhosis, alcoholic hepatitis *
    *(New episode added to BPCI Advanced)
  • Acute myocardial infarction
  • Back & neck except spinal fusion
  • Cardiac arrhythmia
  • Cardiac defibrillator
  • Cardiac valve
  • Cellulitis
  • Cervical spinal fusion
  • COPD, bronchitis, asthma
  • Combined anterior posterior spinal fusion
  • Congestive heart failure
  • Coronary artery bypass graft
  • Double joint replacement of the lower extremity
  • Fractures of the femur and hip or pelvis
  • Gastrointestinal hemorrhage
  • Gastrointestinal obstruction
  • Hip & femur procedures except major joint
  • Lower extremity/humerus procedure except hip, foot, femur
  • Major bowel procedure
  • Major joint replacement of the lower extremity
  • Major joint replacement of the upper extremity
  • Pacemaker
  • Percutaneous coronary intervention
  • Renal failure
  • Sepsis
  • Simple pneumonia and respiratory infections
  • Spinal fusion (non-cervical)
  • Stroke
  • Urinary tract infection

Outpatient Clinical Episodes – 3

  • Percutaneous Coronary Intervention (PCI)
  • Cardiac Defibrillator
  • Back & Neck except Spinal Fusion