medicare cjr patients what codes out

The Centers for Medicare & Medicaid Services (CMS) released guidance on December 9, 2016, stating that claims submitted on or after January 1, 2017, for beneficiaries admitted to a skilled nursing facility (SNF) for care related to Comprehensive Care for Joint Replacement (CJR) will need to include demonstration code 75 in the claim form’s treatment authorization field when the qualifying hospital stay (QHS) criteria aren’t met and a waiver applies.

Full Answer

What is the joint replacement care model for Medicare?

This model aims to improve the care experience for the many and growing numbers of Medicare beneficiaries who receive joint replacements, making the patient’s successful surgery and recovery a top priority for the health care system.

What is the CJR model for patient choice?

Patients can continue to choose their doctor, hospital, skilled nursing facility, home health agency, and other provider, but now with the CJR model, their providers have incentives to better coordinate their care.

When to use patient status code 03 or 04?

If the facility has some Medicare certified beds you should use patient status code 03 or 04 depending on the level of care the patient is receiving and if they are placed in a Medicare certified bed or not Discharged/transferred to a skilled nursing facility (SNF) with Medicare certification with a planned acute care hospital inpatient readmission

Are You no longer a CJR participant hospital?

As of February 1, 2018, they will no longerbe considered CJR participant hospitals and therefore will not be able to use program rule waivers under the model. After February 1, 2018, hospitals that are no longer CJR participant hospitals will only receive data for performance years 1 and 2.

What is Medicare CJR?

The Comprehensive Care for Joint Replacement (CJR) Model is designed to improve care for Medicare patients undergoing hip and knee replacements (also called lower extremity joint replacements or LEJR) performed in the inpatient or outpatient setting and for total ankle replacements performed in the inpatient setting.

Is CJR mandatory?

The final CJR model establishes 34 mandatory metropolitan statistical areas (MSAs), while excluding rural or low-volume hospitals in those geographic areas. Taking into account an additional 33 MSAs in which participation is voluntary, as of January 2021 approximately 432 hospitals participate in the CJR model.

What is the difference between DRG 469 and 470?

This resulted in an MS-DRG change from 469 - Major Joint Replacement or Reattachment of Lower Extremity with MCC to 470 - Major Joint Replacement or Reattachment of Lower Extremity without MCC.

What is a CJR scorecard?

The CJR Composite Quality Score is a score between 0 and 20 and is made up of 3 parts: Hip/Knee Complications – this risk-standardized complication rate is already published on the CMS Hospital Compare website.

What DRG 469?

469 MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPL - Medicare Severity Diagnosis Related Group.

What is arthroplasty in surgery?

Arthroplasty is a surgical procedure to restore the function of a joint. A joint can be restored by resurfacing the bones. An artificial joint (called a prosthesis) may also be used.

What is included in DRG 470?

470 MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC - Medicare Severity Diagnosis Related Group.

What DRG 521?

521 HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC - Medicare Severity Diagnosis Related Group.

What are DRG codes?

DRG Codes (Diagnosis Related Group) Diagnosis-related group (DRG) is a system which classifies hospital cases according to certain groups,also referred to as DRGs, which are expected to have similar hospital resource use (cost). They have been used in the United States since 1983.

What is CJR Air Force?

The Career Job Reservation program is a Headquarters Air Force tool used when needed to manage the number of First Term Airmen and Guardians allowed to reenlist into their current Air Force Specialty Code (AFSC) or Space Force Specialty Code (SFSC) CJR limitations are established to manage projected surpluses and ...

Which of the 4 MIPS program components includes episode based cost measures?

MACRA requires cost measures implemented in MIPS to include consideration of patient condition groups and care episode groups (referred to as “episode groups”).

How are Hcahps surveys conducted?

HCAHPS can be implemented in four different survey modes: mail, telephone, mail with telephone follow-up, or active interactive voice recognition (IVR). Hospitals can use the HCAHPS survey alone, or include additional questions after the core HCAHPS items.

How does CJR help?

How the CJR model helps—and protects—beneficiaries: Patients can benefit from their hospitals and other health care providers (e.g., physicians, home health agencies, and nursing facilities) working together more closely to coordinate their care. Coordination of care leads to better outcomes, a better experience, and fewer complications, ...

Is lower extremity joint replacement a Medicare inpatient surgery?

Lower extremity joint replacements are the most commonly performed Medicare inpatient surgery, and utilization is predicted to continue to grow. These surgeries can require long recoveries that may include extensive rehabilitation or other post-acute care, which provides many opportunities to reward providers that improve patient outcomes.

What is homebound Medicare?

In order for Medicare to pay for home health services, a beneficiary must be determined to be "home bound.” A beneficiary is considered to be confined to the home if the beneficiary has a condition, due to an illness or injury, that restricts his or her ability to leave home except with the assistance of another individual or the aid of a supportive device (that is, crutches, a cane, a wheelchair or a walker) or if the beneficiary has a condition such that leaving his or her home is medically contraindicated. Additional information regarding the homebound requirement is available in the “Medicare Benefit Policy Manual;” Chapter 7,

Does Medicare cover telehealth?

Medicare policy covers and pays for telehealth services when beneficiaries are located in specific geographic areas. Within those geographic areas, beneficiaries must be located in one of the health care settings that are specified in the statute as eligible originating sites. The service must be on the list of approved Medicare telehealth services. Medicare pays a facility fee to the originating site and provides separate payment to the distant site practitioner for the service. Additional information regarding Medicare telehealth services is available in the “Medicare Benefit Policy Manual,” Chapter 15, Section 270 and the “Medicare Claims Processing Manual,” Chapter 12, Section 190.

When will CJR participants no longer receive data?

After February 1, 2018, hospitals that are no longer CJR participant hospitals will only receive data for performance years 1 and 2.

How long should a hospital collect preoperative data?

A: Hospitals should collect a patient’s pre-operative data 90 to 0 days (3 months) prior to the patient’s procedure . The hospital will then need to collect this patient’s post-operative data 270 to 365 days (9 -12 months) after the patient’s procedure. The time for each performance year is presented in Figure 4 below.

When was the EPM final rule published?

In the final rule published on December 1, 2017 , CMS finalized applying the quality categories as established in the EPM final rule (i.e., Below Acceptable (<5), Acceptable (≥5.0 and <6.9), Good (≥6.9 and ≤15.0), and Excellent (>15)) to performance year 1 subsequent, or “final,” reconciliation calculations.

Can a participant hospital receive alignment payments?

Yes, there are several restrictions, specific to the participant hospital and the entity or individual providing the payment: . For a performance year, the aggregate amount of all alignment payments received by the participant hospital must not exceed 50 percent of the participant hospital's repayment amount.

What is the CJR model?

In accordance with this statutory authority, in November 2015 CMS published a final rule for the creation and testing of a new bundled payment model called the CJR model. The CJR model tests bundled payments for Lower Extremity Joint Replacement (LEJR) episodes at acute care hospitals located in multiple geographic areas. The intent of the model is to promote quality

Does CMS waive SNF stay?

CMS waives the SNF 3-day rule for coverage of a SNF stay for a CJR beneficiary following the anchor hospitalization, only if the SNF is identified on the applicable calendar quarter list of qualified SNFs at the time of CJR beneficiary admission to the SNF. CMS will determine all the qualified SNFs for each calendar quarter based on a review of the most recent rolling 12 months of overall star ratings on the Five-Star Quality Rating System for SNFs on the Nursing Home Compare website. All other Medicare rules for coverage and payment of Part A-covered SNF services continue to apply. This will allow payment of claims for SNF services delivered to beneficiaries at eligible sites.

What is LEJR procedure?

An LEJR procedure is attributed to the attending physician's model participation at the time the episode is initiated. In this case, the episode would be included in the CJR model.

Can readmissions be included in episode spending?

Some readmissions may be included in episode spending if they are not excluded for another reason based on the CJR Rule. To find out if there are any readmissions included in your hospital’s episode spending, go to the IPHDR file. Claims where COSTINC = 1 are included in episode spending.

How to Contact The Cjr Model Team

• If you have questions regarding the Model, you can contact the CJR model team by emailing [email protected].

See more on innovation.cms.gov

Additional Information

Relevant Material

Fact Sheets

Participant Resources

Evaluation Reports