what is the cjr medicare

What is comprehensive care for Joint Replacement (CJR)?

The Comprehensive Care for Joint Replacement (CJR) model aims to support better and more efficient care for beneficiaries undergoing the most common inpatient surgeries for Medicare beneficiaries: hip and knee replacements (also called lower extremity joint replacements or LEJR).

What is the CJR model?

The CJR model holds participant hospitals financially accountable for the quality and cost of a CJR episode of care and incentivizes increased coordination of care among hospitals, physicians, and post-acute care providers.

Does the CJR model increase the cost of care?

Some commenters stated that the cost of care for patients who otherwise would have been included in the CJR model would increase, however they did not provide any evidence of how cost of care would increase for their patients, if they were no longer in the model.

What is the CJR model episode definition for hip replacement?

This is because, historically, the CJR model episode definition included MS-DRG 469 (Major Hip and Knee Joint Replacement or Reattachment of Lower Extremity with MCC) and MS-DRG 470 (Major Hip and Knee Joint Replacement or Reattachment of Lower Extremity without MCC).

Is CJR mandatory?

The first mandatory bundled-payment program from the Center for Medicaid and Medicare Services (CMS), known as the Comprehensive Care for Joint Replacement (CJR) model, was implemented with the goal of better supporting patients undergoing the most common inpatient surgeries billed to Medicare: hip and knee ...

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 is CJR in accounting?

CJR reconciliation is the process of comparing actual episode spending with quality-adjusted target pricing to determine potential reconciliation payments (or repayment in future performance years) for CJR episodes.

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 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 ...

How do joint replacements work?

The procedure is performed in a hospital or outpatient surgery center. During the surgery, the damaged cartilage and bone is removed from your joint and replaced with prosthetic components made of metal, plastic, or ceramic. The prosthesis mimics the shape and movement of a natural joint.

What is included in DRG 470?

DRG 470 - Major Joint Replacements or Reattachment of Lower...Top Denials for DRG 470.To Avoid Denials, Include the Following in the Medical Record:Objective Findings to Include in the Physical Examination.Pre-Operative Documentation Should Include Specific Conditions.Post-Operative Documentation.Resources.

What is MS DRG 469?

469 MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT.

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.

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 CJR model?

The CJR Model is a CMS Center for Medicare and Medicaid Innovation (Innovation Center) model that aims to reduce Medicare expenditures while preserving or enhancing quality of care for Medicare beneficiaries. The Model tests whether bundled payment and quality measurement for an episode of care associated with hip and knee replacements to encourage hospitals, physicians, and post-acute care providers to work together to improve the quality and coordination of care from the initial hospitalization through recovery. Under the CJR Model these participant hospitals receive retrospective bundled payments for episodes of care for lower extremity joint replacement or reattachment of a lower extremity (collectively referred to as LEJR). Currently, a CJR episode begins with an inpatient admission for MS-DRG 469 (Major joint replacement or reattachment of lower extremity with major complications or comorbidities) or 470 (Major joint replacement or reattachment of lower extremity without major complications or comorbidities) and includes, with limited exception all care for 90 days following discharge.

How many years does the CJR model last?

The proposed rule proposes several changes to the CJR Model. Most notably, it proposes to extend the CJR Model for an additional 3 performance years, performance year 6 (2021) through performance year 8 (2023).

How long is the CJR model?

Additionally, to allow time to evaluate the proposed changes, the rule proposes to extend the length of the CJR Model for an additional three years, through December 31, 2023, for certain participant hospitals.

When did the CMS issue the rule?

Demonstration projects. Innovation models. Policy. On February 20, 2020, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule in the Federal Register ( https://www.federalregister.gov/public-inspection/current) which proposes a three-year extension and changes to the episode definition and pricing in ...

What is CJR in Medicare?

The CJR program is another means for Medicare to tie payment to quality of care vs quantity of care. By making the providers, or “players” responsible for managing the total cost of care for each beneficiary, communication between post-acute care settings can be improved, thus improving cost and coordination of care.

When does the CJR end?

Designed as a 5-year test, the CJR model begins April 1, 2016, and ends December 31, 2020. Participating hospitals bear the financial risk {or reward} of the episode of care, which include the procedure, inpatient stay, hospital care, post-acute care, and provider services for 90 days.

How much does Medicare pay for hip and knee surgery?

According to CMS, hip and knee surgeries were chosen because they are the most common inpatient surgery for Medicare patients, and they tend to be high-cost, high-utilization procedures with a wide variance in spending-from $16,500 to $33,000.

What is Medicare's goal?

Medicare’s goal is carefully managed and coordinated services to achieve good outcomes. Let’s hope this is true… as therapists should be the only ones controlling the amount of therapy. The last thing therapists want is to transition from a system that rewards more therapy to a system that rewards less therapy.

Is CJR a managed care program?

In essence, the CJR can be described as another type of “managed care” program. Instead of being “managed” by a Managed Medicare entity, the Medicare dollars are managed by the hospitals responsible for the surgery and follow-up care of the resident, the ones holding the “purse.”.

Is Medicare Part B still in place?

The Medicare Part B Therapy Cap is still in place. Remember, this is managed care…and it is still managed profit for the stakeholders. This means there may be a push for things that help the managed care bottom line, including: a shorter length of stay, less equipment, less home care after discharge, etc.

Does CMS waive the 3 day inpatient hospital stay requirement for SNF?

CMS will waive certain rules in order to test the CJR model, specifically: Waiver of the 3 day inpatient hospital stay requirement for eligibility for a covered SNF stay (ie. SNF 3 day rule) ONLY if the SNF is rated 3 stars or higher on Nursing Home Compare (after year 1)

What is CJR in Medicare?

The Comprehensive Care for Joint Replacement (CJR) model, which was implemented via notice-and-comment rulemaking and began on April 1, 2016, aims to support better and more efficient care for beneficiaries undergoing the most common inpatient surgeries for Medicare beneficiaries: Hip and knee replacements (also called lower extremity joint replacements or LEJR). This model tests bundled payment and quality measurement for an episode of care associated with hip and knee replacements to encourage hospitals, physicians, and post-acute care providers to work together to improve the quality and coordination of care from the initial hospitalization through recovery. While initial evaluation results for the first, second, and third year of the CJR model, [ 1] as well as an independent study in the New England Journal of Medicine, [ 2] indicate that the CJR model is having a positive impact on lowering episode costs when CJR participant hospitals are compared to non-CJR participant hospitals (with no negative impacts on quality of care), changes in Medicare program payment policy and national care delivery patterns have occurred since the CJR model began. In order to update the CJR model to address recent policy changes and improve the model's ability to demonstrate savings, we issued a proposed rule titled “Medicare Program: Comprehensive Care for Joint Replacement Model Three-Year Extension and Changes to Episode Definition and Pricing”, which appeared in the February 24, 2020 Federal Register ( 85 FR 10516 ). In this rule, we proposed to change and extend the CJR model for an additional 3 performance years. We proposed to change the definition of a CJR model episode in order to address changes to the inpatient-only (IPO) list, which is a list published annually in the Outpatient Prospective Payment System (OPPS) rule and which contains procedure codes that will only be paid by Medicare when performed in the inpatient setting. Specifically, in response to the change in the calendar year (CY) 2018 OPPS rule ( 65 FR 18455 ), which removed the Total Knee Arthroplasty (TKA) procedure code from the IPO list, and the change in the CY 2020 OPPS rule ( 84 FR 61353 ), which removed the Total Hip Arthroplasty (THA) procedure code from the IPO list, we proposed to change the definition of an episode of care to include outpatient procedures for TKAs and to include outpatient procedures for THAs.

What is CJR model?

The CJR model is a Medicare Part A and B payment model in which acute care hospitals in certain selected geographic areas receive retrospective bundled payments for episodes of care for lower extremity joint replacement or reattachment of a lower extremity ( collectively referred to as LEJR). The CJR model holds participant hospitals financially accountable for the quality and cost of a CJR model episode of care and incentivizes increased coordination of care among hospitals, physicians, and post-acute care providers. All related care covered by Medicare Parts A and B within 90 days of hospital discharge from the LEJR procedure is included in the episode of care. The first CJR model performance period began April 1, 2016. At that time, the CJR model required hospitals located in the 67 MSAs selected for participation to participate in the model through December 31, 2020 unless the hospital was an episode initiator for an LEJR episode in the risk-bearing phase of Models 2 or 4 of the Bundled Payments for Care Improvement (BPCI) initiative. Hospitals located in one of the 67 MSAs that participated in Model 1 of the BPCI initiative, which ended on December 31, 2016, were required to begin participating in the CJR model when their participation in the BPCI initiative ended.

What are the two quality measures included in the CJR model?

The two quality measures included in the CJR model are the THA and/or TKA Complications measure (NQF #1550) and the HCAHPS Survey measure (NQF #0166). The model also incentivizes the submission of THA/TKA PRO and limited risk variable data. We proposed to advance the Complications and HCAHPS performance periods for PYs 6 through 8 in alignment with the performance periods used for PYs 1 through 5. For PRO, we also proposed to advance the performance periods in alignment with previous performance periods as well as make changes to the thresholds for successful submission. We proposed to make these changes to the thresholds for successful submission as participant hospitals gain experience Start Printed Page 23544 with PRO and to continue the trend of increased thresholds set by the earlier performance years of the model. These proposed changes are outlined in Table 5.

What is participant hospital detailed notification?

Under current regulations, the participant hospital detailed notification informs Medicare beneficiaries of their inclusion in the CJR model and provides an in-paper, detailed explanation of the model, either upon admission to the participant hospital if the admission is not scheduled in advance, or as soon as the admission is scheduled. We proposed to change the definition of an episode of care to include outpatient procedures, for which the beneficiary would not be admitted to the participant hospital. We also proposed to add the definition of anchor procedure to mean a TKA or THA procedure that is permitted and payable by Medicare when performed in the outpatient setting and billed through the OPPS. We believe that the beneficiary should be notified of his or her inclusion in the CJR model whether the procedure takes place in an inpatient or outpatient setting. Therefore, we proposed changes for the participant hospital detailed notification at 42 CFR 510.405 (b) (1) to clarify that if the anchor procedure or anchor hospitalization is scheduled in advance, then the participant hospital must provide notice as soon as the anchor procedure or anchor hospitalization is scheduled. Further, we proposed if the anchor procedure or anchor hospitalization is not scheduled in advance, then the notification must be provided on the date of the anchor procedure or date of admission to the anchor hospitalization.

How long is CJR?

This final rule extends the length of the Comprehensive Care for Joint Replacement (CJR) model through December 31, 2024 by adding an additional 3 performance years (PYs). PY 6 will begin on October 1, 2021 and end on December 31, 2022; PY 7 will begin on January 1, 2023 and end on December 31, 2023; and PY 8 will begin on January 1, 2024 and end on December 31, 2024. In addition, this final rule revises certain aspects of the CJR model including the episode of care definition, the target price calculation, the reconciliation process, the beneficiary notice requirements, and the appeals process. In addition, for PY 6 through 8, this final rule eliminates the 50 percent cap on gainsharing payments, distribution payments, and downstream distribution payments for certain recipients. This final rule extends the additional flexibilities provided to participant hospitals related to certain Medicare program rules consistent with the revised episode of care definition.

When did CJR start?

The CJR model began on April 1, 2016. The CJR model is currently in its fifth performance year. The fifth performance year, which was extended to include all episodes ending on or after January 1, 2020 and on or before September 30, 2021, would necessarily incorporate episodes that began before January 1, 2020. As previously discussed in section I.C. of this final rule, the CJR model was created to bundle care for beneficiaries of Medicare Part A and Part B undergoing LEJR procedures, and in so doing, to decrease the cost and improve the quality of that care ( 80 FR 73274 ).

What is a small rural hospital?

For purposes of section 1102 (b) of the Act, a small rural hospital is defined as a hospital that is located outside of an MSA and has fewer than 100 beds. We note that, according to this definition, the CJR model has never included any rural hospitals given that the CJR model only includes hospitals located in MSAs. However, for purposes of our policy to provide a more protective stop-loss policy for certain hospitals, in the November 2015 final rule we revised our definition of a rural hospital to include an IPPS hospital that is either located in a rural area in accordance with § 412.64 (b) or in a rural census tract within an MSA defined at § 412.103 (a) (1), or has reclassified to rural in accordance with § 410.103.

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