Proposed rule would extend CJR model, retool definitions and target price calculation

February 26, 2020
Medicare Web

CMS is proposing several changes to the Comprehensive Care for Joint Replacement (CJR) model, including a three-year extension, in a proposed rule published in the Federal Register on  February 24.

The CJR model was launched in April 2016 and is currently set to expire on December 31, 2020. The model was established to test bundled payment and quality measures for entire episodes of care associated with total hip arthroplasty (THA) and total knee arthroplasty (TKA).

An episode of care begins when a patient is admitted to a participating hospital and ends 90-days after discharge. Participating hospitals receive retrospective bundled payments for the specified procedures, making them financially accountable for providing high-quality care in the most cost-effective manner. The overall goal is to encourage hospitals, physicians, and postacute providers to collaborate and coordinate care. The proposed rule would extend the model to December 31, 2023.

CMS is also proposing changes to its definition of an episode of care. Currently, because the covered procedures were on the inpatient-only list when the model was developed, the model applies only to inpatient procedures. In the 2018 Outpatient Prospective Payment System final rule, TKA was removed from the inpatient-only list. To ensure consistency across programs, appropriate data collection, and address site-neutrality concerns, CMS is proposing to expand the definition of an episode of care to include permitted outpatient TKAs and THAs.

The proposed rule also floats the possibility of changing the basis for the target price calculation from three years of claims data to the most recent one year of claims data.

CMS is seeking public comments on the proposed rule. Comments are due April 24. Participating organizations and other interested stakeholders should carefully review the proposed rule and determine how the changes may impact their organization. When submitting a comment, consider those specific aspects for which CMS is soliciting comments. Also, keep in mind that CMS’ primary concerns are the well-being of Medicare beneficiaries and the financial sustainability of the Medicare program.

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Billing and reimbursement