Collapse to view only § 510.210 - Determination of the episode.
- § 510.200 - Time periods, included and excluded services, and attribution.
- § 510.205 - Beneficiary inclusion criteria.
- § 510.210 - Determination of the episode.
§ 510.200 - Time periods, included and excluded services, and attribution.
(a) Time periods. All episodes must begin on or after April 1, 2016 and end on or before December 31, 2024.
(b) Included services. All Medicare Parts A and B items and services are included in the episode, except as specified in paragraph (d) of this section. These services include, but are not limited to, the following:
(1) Physicians' services.
(2) Inpatient hospital services (including hospital readmissions).
(3) IPF services.
(4) LTCH services.
(5) IRF services.
(6) SNF services.
(7) HHA services.
(8) Hospital outpatient services.
(9) Outpatient therapy services.
(10) Clinical laboratory services.
(11) DME.
(12) Part B drugs and biologicals.
(13) Hospice services.
(14) PBPM payments under models tested under section 1115A of the Act.
(15) The surgeon's Part B claim for the LEJR procedure dated within the 3 days prior to an inpatient admission, if the LEJR procedure was performed at the participant hospital on an outpatient basis but the patient was subsequently admitted as an inpatient, resulting in an anchor hospitalization.
(c) Episode attribution. All items and services included in the episode are attributed to the participant hospital at which the anchor hospitalization or anchor procedure, as applicable, occurs.
(d) Excluded services. The following items, services, and payments are excluded from the episode:
(1) Hemophilia clotting factors provided in accordance with § 412.115 of this chapter.
(2) New technology add-on payments, as defined in part 412, subpart F of this chapter.
(3) Transitional pass-through payments for medical devices as defined in § 419.66 of this chapter.
(4) Items and services unrelated to the anchor hospitalization or the anchor procedure. Excluded services include, but are not limited, to the following:
(i) Inpatient hospital admissions for MS-DRGs that group to the following categories of diagnoses:
(A) Oncology.
(B) Trauma medical.
(C) Chronic disease surgical, such as prostatectomy.
(D) Acute disease surgical, such as appendectomy.
(ii) Medicare Part B services, as identified by the principal ICD-CM diagnosis code on the claim (based on the ICD-CM version in use during the performance year) that group to the following categories of diagnoses:
(A) Acute disease diagnoses, such as severe head injury.
(B) Certain chronic disease diagnoses, as specified by CMS on a diagnosis-by-diagnosis basis depending on whether the condition was likely to have been affected by the LEJR procedure and recovery period or whether substantial services were likely to be provided for the chronic condition during the episode. Such chronic disease diagnoses are posted on the CMS Web site and may be revised in accordance with paragraph (e) of this section.
(iii) Certain PBPM payments under models tested under section 1115A of the Act. PBPM model payments that CMS determines to be primarily used for care coordination or care management services for clinical conditions in excluded categories of diagnoses, as described in this paragraph.
(A) The list of excluded PBPM payments is posted on the CMS Web site and are revised in accordance with paragraph (e) of this section.
(B) Notwithstanding the foregoing, all PBPM model payments funded from CMS' Innovation Center appropriation are excluded from the episode.
(5) Certain incentive programs and add on payments under existing Medicare payment systems in accordance with § 510.300(b)(6) of this chapter.
(6) For performance years 1 through 4 and for performance year subsets 5.1 and 5.2, payments for otherwise included items and services in excess of 2 standard deviations above the mean regional episode payment in accordance with § 510.300(b)(5).
(7) For performance years 6 through 8 only, payments for otherwise included items and services in excess of the 99th percentile of regional spending, ranked within each region, for each of the four MS-DRG target price categories, as specified in § 510.300(a)(1) and (6), for performance years 6 through 8, in accordance with § 510.300(b)(5).
(e) Updating the lists of excluded services. (1) The list of excluded MS-DRGs, ICD-CM diagnosis codes, and CMS model PBPM payments are posted on the CMS Web site.
(2) For performance years 1 through 5 only, on an annual basis, or more frequently as needed, CMS updates the list of excluded services to reflect annual coding changes or other issues brought to CMS' attention.
(3) For performance years 1 through 5 only, CMS applies the following standards when revising the list of excluded services for reasons other than to reflect annual coding changes:
(i) Items or services that are directly related to the LEJR procedure or the quality or safety of LEJR care would be included in the episode.
(ii) Items or services for chronic conditions that may be affected by the LEJR procedure or post-surgical care would be related and included in the episode.
(iii) Items and services for chronic conditions that are generally not affected by the LEJR procedure or post-surgical care would be excluded from the episode.
(iv) Items and services for acute clinical conditions not arising from existing, episode-related chronic clinical conditions or complications of LEJR surgery would be excluded from the episode.
(v) PBPM payments under CMS models determined to be primarily used for care coordination or care management services for clinical conditions in excluded categories of diagnoses, as described in § 510.200(d), would be excluded from the episode.
(4) For performance years 1 through 5 only, CMS posts the following to the CMS website:
(i) Potential revisions to the exclusion to allow for public comment; and
(ii) An updated exclusions list after consideration of public comment.
(5) For performance years 6 through 8, the list of excluded services posted on the CMS website as it appears at the beginning of performance year 5 will apply and will not be updated.
§ 510.205 - Beneficiary inclusion criteria.
(a) Episodes tested in the CJR model include only those in which care is furnished to beneficiaries who meet all of the following criteria upon admission to the anchor hospitalization:
(1) Are enrolled in Medicare Parts A and Part B.
(2) Eligibility for Medicare is not on the basis of end stage renal disease, as described in § 406.13 of this chapter.
(3) Are not enrolled in any managed care plan (for example, Medicare Advantage, health care prepayment plans, or cost-based health maintenance organizations).
(4) Are not covered under a United Mine Workers of America health care plan.
(5) Have Medicare as their primary payer.
(6) For episodes beginning on or after July 1, 2017, are not prospectively assigned to—
(i) An ACO in the Next Generation ACO model;
(ii) An ACO in a track of the Comprehensive ESRD Care Model incorporating downside risk for financial losses; or
(iii) A Shared Savings Program ACO in the ENHANCED track (formerly Track 3).
(b) If at any time during the episode a beneficiary no longer meets all of the criteria in this section, the episode is canceled in accordance with § 510.210(b).
§ 510.210 - Determination of the episode.
(a) General. (1) An episode begins with the admission of a Medicare beneficiary described in § 510.205 to a participant hospital for an anchor hospitalization and ends on the 90th day after the date of discharge, with the day of discharge itself being counted as the first day in the 90-day post-discharge period.
(2) On or after July 4, 2021, an episode—
(i) Begins and ends in the manner specified in paragraph (a)(1) of this section; or
(ii) Begins on the date of service of an anchor procedure furnished to a Medicare beneficiary described in § 510.205 and ends on the 90th day after the date of service of the anchor procedure.
(b) Cancellation of an episode. The episode is canceled and is not included in the determination of NPRA as specified in § 510.305 if any of the following occur:
(1) The beneficiary does any of the following during the episode:
(i) Ceases to meet any criterion listed in § 510.205.
(ii) Is readmitted to any participant hospital for another anchor hospitalization, or, on or after July 4, 2021, receives an anchor procedure at any participant hospital.
(iii) Initiates an LEJR episode under BPCI.
(iv) Dies.
(2) For performance year 3, the participant hospital did not submit a participation election letter that was accepted by CMS to continue participation in the model.