At the Margins

Your questions about Comprehensive Care for Joint Replacement—answered

by Natalie McGarry

On Monday Aug. 17 we hosted a webconference on CMS’s proposed rule for the Comprehensive Care for Joint Replacement (CCJR) model, Medicare’s first mandatory bundling program.

The webconference covered all the basics, the CCJR episode, the target price, and the reconciliation process, in addition to gainsharing rules, program waivers, and beneficiary considerations. But the rule is complex and there’s a lot of misinformation in the media discussion.

To help you cut through the noise, here are the most frequently asked questions we’ve received about the rule.

1. Are the quality metrics weighted in any way, or is it all or nothing?

The quality metrics are not weighted in any way. If a participant hospital falls below the 30th percentile nationally on any of the three required quality metrics (THA/THK readmissions, THA/TKA complications, HCAHPS scores) then the hospital is not eligible to receive any reconciliation payments from CMS. CMS did discuss a weighted quality score in the proposed rule, but ultimately decided not to officially propose that option, which may be the source of the confusion.

2. We are in BPCI bundled payments for CABG & valves, are we exempt from mandatory CCJR program?

The short answer is no. The CCJR program is mandatory for all IPPS hospitals that fall into the designated metropolitan service areas (MSAs), with a few exceptions. Any IPPS hospital participating in BPCI Model 1 or risk-bearing for lower extremity joints under model 2 or 4 are also exempt, meaning that bearing risk for CABG and valves under BPCI would not qualify as an exemption.

3. If a SNF participates in Model 3 BPCI for lower extremity joints, does that BPCI episode trump the CCJR episode?

Yes. A hospital participating in CCJR will have all of their MS-DRG 469 and 470 discharges counted towards their episode spending and reconciliation, however, the BPCI program takes precedent over CCJR. Any episodes that are initiated or managed by a provider bearing risk under BPCI Model 2 or 3 are not counted as CCJR episodes, meaning they will be excluded from the participating hospital’s reconciliation process. CMS believes that providers will have limited ability to purposefully steer patients to Model 3 SNFs to avoid financial responsibility, since CMS has proposed to maintain patient choice and does not allow hospitals to restrict the post-acute care provider list.

4. Does a readmission to SNF or LTACH count towards the THA/TKA readmissions quality metric?

No. Only readmissions to acute care facilities count towards the readmissions quality metric, meaning readmission to SNF and LTACH would count towards episode spend, but would not impact the readmissions quality metric.

5. Due to the home health “incident to” waiver, physicians can see a patient in their home and bill for those services for up to 9 visits during the 90 day episode. What about in the SNF setting? Can an MD see the patient and bill every day?

No. The waiver was exclusive to the home health setting and does not extend to SNF. The home health “incident to” waiver allows patient who are not homebound to receive services in their home, although those services will be billed under a new HCPCS code, not as home health services. That being said, there is a waiver of the SNF 3-day rule which takes effect in year 2 of the model. The SNF waiver allows hospitals to discharge CCJR patients to SNF with an inpatient stay of fewer than 3 days, as long as the patient is discharged to a SNF with a 3-star quality rating or higher.

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