Tuesday, 11 October 2016 03:40

Proposed Rule for Mandatory Episode Payment Models for AMI and CABG and Cardiac Rehab Incentive Payment

Written by Kim Charland, BA, RHIT, CCS and Contributor Rhonda Taller, MHA

The August 2 issue of the Federal Register includes a proposed rule issued by the Centers for Medicare & Medicaid Services (CMS) entitled Advancing Care Coordination through Episode Payment Models (EPMs). The 60-day comment period ended on October 3. 

The proposed rule includes details on the new, retrospective mandatory EPMs for acute myocardial infarction (AMI), triggered by an AMI admission and for percutaneous coronary intervention (PCI) treatment for AMI patients. It also includes a new mandatory episode for coronary artery bypass graft (CABG) admissions. Similar to the Comprehensive Care for Joint Replacement (CJR) mandatory episode, which began in April, the hospital is the entity at financial risk.

The proposed rule includes a path for eligible clinicians (who meet the criteria as a qualified participant) to qualify for Advanced Alternative Payment Model status (under the Medicare Access and CHIP Reauthorization Act or MACRA) through EPM participation beginning in April 2018. Also included in the proposed rule is a cardiac rehabilitation (CR) incentive payment intended to increase utilization of CR services for Medicare beneficiaries.

CMS will select and announce the 98 geographic areas for AMI and CABG participation in the final rule.  The mandatory episode is scheduled to begin in July 2017 and conclude in December 2021 (downside risk begins in year two following one-year participation in upside participation that spans 2017 and the first quarter of 2018).

As proposed, the AMI and CABG EPMs begin with inpatient admission to an anchor hospital and would include medical and surgical services provided to Medicare patients both during the inpatient hospitalization through 90 days post-discharge. 

All episodes are triggered by an inpatient admission and include MS-DRGs.  For the AMI episode, this includes MS-DRGs 280–282 or, in the case of PCI treatment, MS-DRGs 246–251. For the CABG episode, this includes MS-DRGs 231–236. 

The proposed episode models include both Part A and B services. There are some proposed exclusions for hospitals participating in the voluntary Bundled Payments for Care Improvement (BPCI) Initiative for AMI, PCI or CABG episodes or certain rural counties.  The proposed model includes quality targets for both AMI and CABG episodes.  For AMI, CMS proposes four quality measures (three required and one voluntary measure) and two required measures for CABG.  The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey data completed by Medicare beneficiaries is included among the measures for both AMI and CABG.

For the cardiac rehab incentive payment, a retrospective payment will be included based on the use of these services by Medicare beneficiaries (attributed to participant hospitals). These payments will be added to the standard Medicare cardiac-rehab payments for services provided to Medicare beneficiaries through the five-year model duration with no downside risk included. 

As proposed, this includes an initial payment of $25 for each of the first 11 services with the payment increasing to $175 per service following the initial 11 services. CMS has signaled, in the proposed rule, its intent to select 90 geographic areas for the cardiac rehab hospital participants, 45 where the AMI and CABG episodes are slated for implementation and 45 geographic areas not selected.  It is anticipated that CMS will publish the final rule prior to year-end.

About the Author

Kim Charland is the editor of VBPmonitor and the senior vice president of clinical innovation with Panacea Healthcare Solutions. Kim has 30 years of experience in health information and reimbursement management for hospitals and physician offices. Kim’s primary role with Panacea is publisher of VBPmonitor.com, which is the company’s newest online monitor and is focused on value-based purchasing and quality. She is also co-host of ICD10monitor.com’s Internet news broadcast Talk-Ten-Tuesdays. In addition, she assists with product development for Panacea’s consulting and software divisions, as well as the MedLearn publishing division. Kim is also recognized as a national speaker who has spoken for numerous organizations.

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Last modified on Tuesday, 11 October 2016 04:13