title: Bundling in medicare patients undergoing bidirectional endoscopy: how often does it happen?
abstract: OBJECTIVE
  In patients with appropriate indications, performance of both colonoscopy and esophagogastroduodenoscopy (EGD) at the same time (bundling) is convenient for patients, efficient for providers, and cost saving for the health care system. However, Medicare reimbursement for bundled procedures is at a rate that is less than the sum of the 2 procedures when charged separately, and this may create a disincentive to bundle. The practice patterns of bundling are unknown at a US population-based level.
  
  
  METHODS
  We examined Medicare claims from 2007 to 2009 from the Carrier file in a national, random sample of fee-for-service beneficiaries aged 66 and older. We identified patients who had both a colonoscopy and EGD performed within 180 days of each other and calculated the proportions of patients with both procedures bundled on the same date, within 1 to 30 days, and within 31 to 180 days of each other. We compared patients in these 3 groups for demographics and clinical indications for the procedures (bleeding, lower or upper gastrointestinal symptoms, surveillance, and screening).
  
  
  RESULTS
  We identified 12,982 Medicare-enrolled individuals who had a colonoscopy and an EGD performed within 180 days of each other. Approximately 35% of procedures were not bundled on the same day, and, of these, 2359 (18%) were performed within 30 days of each other, and 2219 (17%) were performed within 31 to 180 days of each other. There were marked geographic differences in the percentage of bundling, with the lowest occurrence in the Northeast and the highest in the West. Patients with bundled procedures were more likely to have gastrointestinal bleeding and less likely to have screening or surveillance indications.
  
  
  CONCLUSIONS
  Although same-day bundling of endoscopic procedures offers a number of advantages, it is not practiced in more than one-third of cases in a national sample of Medicare beneficiaries.
authors.affiliation: Section of Gastroenterology and Hepatology, Department of Medicine, Michael E. DeBakey Veterans Affairs Medical Center, Baylor College of Medicine, Houston, Texas. Electronic address: hasheme@bcm.edu.
authors.forename: Hashem B
authors.initials: HB
authors.lastname: El-Serag
authors.affiliation: Division of Gastroenterology, University Hospitals Case Medical Center and Comprehensive Cancer Center, Case Western Reserve University, Cleveland, Ohio.
authors.forename: Fang
authors.initials: F
authors.lastname: Xu
authors.affiliation: Division of Gastroenterology, University Hospitals Case Medical Center and Comprehensive Cancer Center, Case Western Reserve University, Cleveland, Ohio.
authors.forename: Prachi
authors.initials: P
authors.lastname: Biyani
authors.affiliation: Division of Gastroenterology, University Hospitals Case Medical Center and Comprehensive Cancer Center, Case Western Reserve University, Cleveland, Ohio.
authors.forename: Gregory S
authors.initials: GS
authors.lastname: Cooper
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D003113:Colonoscopy / Q000379:methods / Q000706:statistics & numerical data*; D016145:Endoscopy, Digestive System / Q000379:methods / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D007349:Insurance, Health, Reimbursement; D008297:Male; D006278:Medicare; D014481:United States
keywords: Colonoscopy; EGD; GI; Health Services Research; ICD-9-CM; Insurance; International Classification of Diseases, 9th revision, Clinical Modification; Medicare; UPIN; Unique Physician Identification Number; esophagogastroduodenoscopy; gastrointestinal
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