§ 512.605 Definitions.
For the purposes of this subpart, the following definitions are applicable unless otherwise stated:
AAPM stands for Advanced Alternative Payment Model.
AAPM option means the advanced alternative payment model option for CJR-X participants that provide their CMS EHR Certification ID and attest to their use of CEHRT in accordance with § 512.615.
ACO means an accountable care organization, as defined at § 425.20 of this chapter.
ACO participant has the meaning set forth in § 425.20 of this chapter.
ACO provider/supplier has the meaning set forth in § 425.20 of this chapter.
Acute care hospital means a provider subject to the prospective payment system specified in § 412.1(a)(1) of this chapter.
Age bracket risk adjustment factor means the coefficient of risk associated with a patient's age bracket, calculated as described in § 512.645(a)(1).
Aggregated reconciliation target price means the sum of the reconciliation target prices for all episodes attributed to a CJR-X participant for the applicable performance year.
Alignment payment means a payment from a CJR-X collaborator to a CJR-X participant under a sharing arrangement, for the sole purpose of sharing the CJR-X participant's responsibility for making repayments to Medicare.
Anchor hospitalization means the initial hospital stay upon admission for a lower extremity joint replacement for which the institutional claim is billed through the inpatient prospective payment system (IPPS).
Anchor procedure means a TKA or THA procedure that is permitted and paid for by Medicare when performed in a hospital outpatient department (HOPD) and billed through the Hospital Outpatient Prospective Payment System (OPPS).
APM stands for Alternative Payment Model as defined in § 414.1305 of this chapter.
Baseline episode spending means the total episode spending by all providers and suppliers associated with a given MS-DRG/HCPCS episode type for all hospitals in a given region during the baseline period.
Baseline period means the 3-year historical period CMS uses to construct the preliminary target price and reconciliation target price for a given performance year.
Baseline year means any one of the three years included in the baseline period.
Benchmark price means the average standardized episode spending by all providers and suppliers associated with an MS-DRG/HCPCS episode type for all hospitals in a defined region during the applicable baseline period.
Beneficiary economic risk adjustment factor means the coefficient of risk associated with a patient's economic status, calculated as described in § 512.645(a)(3).
CCN stands for CMS certification number.
CDI stands for Community Deprivation Index.
CEHRT means certified electronic health record technology that meets the requirements set forth in § 414.1305 of this chapter.
CJR stands for the Comprehensive Care for Joint Replacement Model, that was the Phase I episode-based payment model test by the Innovation Center from April 2016 to December 2024.
CJR-X stands for the Comprehensive Care for Joint Replacement Expanded Model.
CJR-X activities mean any activity related to promoting accountability for the quality, cost, and overall care for CJR-X beneficiaries and performance in the model, including managing and coordinating care, encouraging investment in infrastructure and redesigned care processes for high quality and efficient service delivery, or carrying out any other obligation or duty under the model.
CJR-X beneficiary means a beneficiary who meets the beneficiary inclusion criteria in § 512.620.
CJR-X collaborator means an ACO or one of the following Medicare-enrolled individuals or entities that enters into a sharing arrangement:
(1) Skilled Nursing Facility (SNF).
(2) Home Health Agency (HHA).
(3) Long-Term Care Hospital (LTCH).
(4) Inpatient Rehabilitation Facility (IRF).
(5) Physician.
(6) Nonphysician practitioner.
(7) Therapist in private practice.
(8) Comprehensive Outpatient Rehabilitation Facility (CORF).
(9) Provider of outpatient therapy services.
(10) Physician Group Practice (PGP).
(11) Hospital.
(12) Critical Access Hospital (CAH).
(13) Non-Physician Provider Group Practice (NPPGP).
(14) Therapy Group Practice (TGP).
CJR-X data sharing agreement means an agreement between the CJR-X participant and CMS that includes the terms and conditions for any beneficiary-identifiable data shared with the CJR-X participant under § 512.665.
CJR-X HCC count risk adjustment factor means the CJR-X Hierarchical Condition Category count that is a categorical risk adjustment variable that reflects a beneficiary's overall health status during a 180-day lookback period that groups similar diagnoses into one related category and counts the total number of diagnostic categories that apply to the beneficiary.
CJR-X participant means an acute care hospital located in any of the 50 United States, District of Columbia, or U.S. Territories that initiates LEJR episodes and is eligible to be paid under both the IPPS and OPPS, unless it meets an exception in § 512.610(b).
CJR-X payment means a payment made by CMS only to CJR-X participants, or a payment adjustment made only to payments made to CJR-X participants, under the terms of CJR-X that is not applicable to any other providers or suppliers.
CJR-X reconciliation report means the report prepared after each reconciliation that CMS provides to each CJR-X participant notifying the CJR-X participant of the outcome of the reconciliation.
Clinician engagement list means the list of eligible clinicians or MIPS eligible clinicians that participate in CJR-X activities and have a contractual relationship with the CJR-X participant, and who are not listed on the financial arrangements list, as described in § 512.615(c).
CMS Electronic Health Record (EHR) Certification ID means the identification number that represents the combination of Certified Health Information Technology that is owned and used by providers and hospitals to provide care to their patients and is generated by the Certified Health Information Technology Product List.
Collaboration agent means an individual or entity that is not a CJR-X collaborator and that is either of the following:
(1) A member of a PGP, NPPGP, or TGP that has entered into a distribution arrangement with the same PGP, NPPGP, or TGP in which he or she is an owner or employee, and where the PGP, NPPGP, or TGP is a CJR-X collaborator.
(2) An ACO participant or ACO provider/supplier that has entered into a distribution arrangement with the same ACO in which it is participating, and where the ACO is a CJR-X collaborator.
Composite quality score (CQS) means a score computed for each CJR-X participant to summarize the CJR-X participant's level of quality performance on specified quality measures as described in § 512.635.
CORF stands for comprehensive outpatient rehabilitation facility.
Critical access hospital (CAH) means a hospital designated under subpart F of part 485 of this chapter.
Discount factor means a set percentage included in the preliminary target price and adjusted for quality at reconciliation as described at § 512.645(g).
Distribution arrangement means a financial arrangement between a CJR-X collaborator that is an ACO, PGP, NPPGP, or TGP and a collaboration agent for the sole purpose of distributing some or all of a gainsharing payment received by the ACO, PGP, NPPGP, or TGP.
Distribution payment means a payment from a CJR-X collaborator that is an ACO, PGP, NPPGP, or TGP to a collaboration agent, under a distribution arrangement, composed only of gainsharing payments.
DME stands for durable medical equipment.
Downstream collaboration agent means an individual who is not a CJR-X collaborator or a collaboration agent and who is a member of a PGP, NPPGP, or TGP that has entered into a downstream distribution arrangement with the same PGP, NPPGP, or TGP in which he or she is an owner or employee, and where the PGP, NPPGP, or TGP is a collaboration agent.
Downstream distribution arrangement means a financial arrangement between a collaboration agent that is both a PGP, NPPGP, or TGP and an ACO participant and a downstream collaboration agent for the sole purpose of sharing a distribution payment received by the PGP, NPPGP, or TGP.
Downstream participant means an individual or entity that has entered into a written arrangement with a CJR-X participant, CJR-X collaborator, collaboration agent, or downstream collaboration agent under which the downstream participant engages in one or more CJR-X activities.
Dually eligible beneficiary means a beneficiary enrolled in both Medicare and full Medicaid benefits.
EHR stands for electronic health record.
Eligible clinician means a clinician as defined in § 414.1305 of this chapter.
Episode means all Medicare Part A and B items and services described in § 512.625(b) (and excluding the items and services described in § 512.625(c)) that are furnished to a CJR-X beneficiary during the time period that begins on the date of the beneficiary's admission to an anchor hospitalization or the date of the anchor procedure, as described at § 512.630(c), and ends on the 90th day following the date of discharge from the anchor hospitalization or anchor procedure, as described at § 512.630(d).
Episode type means the subset of episodes that are associated with a given MS-DRG/HCPCS, as set forth at § 512.640(a)(1).
Final normalization factor means the mathematical mean of the benchmark price for each MS-DRG/HCPCS episode type and region divided by the mean of the risk-adjusted benchmark price for the same MS-DRG/HCPCS episode type and region.
Financial arrangements list means the list of eligible clinicians or MIPS eligible clinicians that have a financial arrangement with the CJR-X participant, CJR-X collaborator, collaboration agent, and downstream collaboration agent, as described in § 512.615(b).
Gainsharing payment means a payment from a CJR-X participant to a CJR-X collaborator, under a sharing arrangement, composed of only reconciliation payments, internal cost savings, or both.
HCPCS stands for Healthcare Common Procedure Coding System and means the system used to bill for items and services.
HHA means a Medicare-enrolled home health agency.
High-cost outlier cap means the CMS-applied episode spending cap at the 99th percentile of regional spending for a given MS DRG/HCPCS episode type, region, and baseline year.
Hospital means a hospital as defined in section 1886(d)(1)(B) of the Act.
Hospital discharge planning means the standards set forth in § 482.43 of this chapter.
ICD-CM stands for International Classification of Diseases, Clinical Modification.
Inpatient measure composite quality score means the sum of inpatient quality measure point values capped at 20 points.
Internal cost savings means the measurable, actual, and verifiable cost savings realized by the CJR-X participant resulting from care redesign undertaken by the CJR-X participant in connection with providing items and services to CJR-X beneficiaries within an episode. Internal cost savings does not include savings realized by any individual or entity that is not the CJR-X participant.
IPF stands for inpatient psychiatric facility.
IPPS stands for Inpatient Prospective Payment System, and means the payment system for subsection (d) hospitals as defined in section 1886(d)(1)(B) of the Act.
IRF stands for inpatient rehabilitation facility.
LIS stands for Medicare Part D Low-Income Subsidy.
Lower-extremity joint replacement (LEJR) means any hip, knee, or ankle replacement that is paid under MS-DRG 469, 470, 521, or 522 through the IPPS or HCPCS code 27447 or 27130 through the OPPS.
Low-volume hospital means a hospital identified by CMS as having fewer than 31 LEJR episodes during the applicable baseline period.
LTCH stands for long-term care hospital as defined in section 1861(ccc) of the Act.
Medicare severity diagnosis-related group (MS-DRG) means, for the purposes of this model, the classification of inpatient hospital discharges updated in accordance with § 412.10 of this chapter.
Medicare-dependent, small rural hospital (MDH) means a specific type of hospital that meets the classification criteria specified under § 412.108 of this chapter.
Member of the NPPGP or NPPGP member means a nonphysician practitioner or therapist who is an owner or employee of an NPPGP and who has reassigned to the NPPGP his or her right to receive Medicare payment.
Member of the PGP or PGP member means a physician, nonphysician practitioner, or therapist who is an owner or employee of the PGP and who has reassigned to the PGP his or her right to receive Medicare payment.
Member of the TGP or TGP member means a therapist who is an owner or employee of a TGP and who has reassigned to the TGP his or her right to receive Medicare payment.
MIPS stands for Merit-based Incentive Payment System
MIPS eligible clinician means a clinician as defined in § 414.1305 of this chapter.
Model start date means the start of the Phase II model test on January 1, 2028.
Non-AAPM option means the CJR-X participant's choice to not attest to the use of CEHRT as described in § 512.615.
Nonphysician practitioner means one of the following:
(1) A physician assistant who satisfies the qualifications set forth at § 410.74(a)(2)(i) and (ii) of this chapter.
(2) A nurse practitioner who satisfies the qualifications set forth at § 410.75(b) of this chapter.
(3) A clinical nurse specialist who satisfies the qualifications set forth at § 410.76(b) of this chapter.
(4) A certified registered nurse anesthetist (as defined at § 410.69(b)).
(5) A clinical social worker (as defined at § 410.73(a)).
(6) A registered dietician or nutrition professional (as defined at § 410.134).
NPI stands for National Provider Identifier.
NPPGP stands for non-physician provider group practice and means an entity that is enrolled in Medicare as a group practice, includes at least one owner or employee who is a nonphysician practitioner, does not include a physician owner or employee, and has a valid and active TIN.
Net payment reconciliation amount (NPRA) means the dollar amount calculated in accordance with § 512.650(c).
OIG stands for the Department of Health and Human Services' Office of Inspector General.
OP means an outpatient procedure for which the institutional claim is billed by the hospital through the OPPS.
OPPS stands for the Outpatient Prospective Payment System.
Outpatient composite quality score means the sum of outpatient quality measure points values, capped at 20 points.
Overall composite quality score means the sum of the weighted average of the inpatient measure composite quality score and the outpatient measure composite quality score, capped at 20 points.
PAC stands for post-acute care.
PAC provider is a home health agency (HHA), skilled nursing facility (SNF), inpatient rehabilitation facility (IRF), or long-term care hospital (LTCH), as defined in section 1899B(a)(2) of the Act.
Performance year (PY) means a 12-month period beginning on January 1 and ending on December 31 to align with the calendar year.
Performance year spending means the sum of standardized Medicare claims payments during a performance year for the items and services that are included in the episode in accordance with § 512.625(b), excluding the items and services described in § 512.625(c).
PGP stands for physician group practice.
Physician has the meaning set forth in section 1861(r) of the Act.
Preliminary target price means the CMS-set financial amount provided to the CJR-X participant prior to the start of the performance year, that is subject to adjustment at reconciliation, as set forth at § 512.640.
Prospective normalization factor means the multiplier used by CMS in the preliminary target price calculation to ensure that the average of the total risk-adjusted benchmark price does not exceed the average of the total non-risk adjusted benchmark price, calculated as set forth in § 512.640(b)(6).
Prospective trend factor means the multiplier used by CMS in the preliminary target price calculation to estimate changes in spending patterns between the baseline period and the performance year, calculated as set forth in § 512.640(b)(7).
Provider of outpatient therapy services means an entity that is enrolled in Medicare as a provider of therapy services and furnishes one or more of the following:
(1) Outpatient physical therapy services as defined in § 410.60 of this chapter.
(2) Outpatient occupational therapy services as defined in § 410.59 of this chapter.
(3) Outpatient speech-language pathology services as defined in § 410.62 of this chapter.
Reconciliation payment amount means the amount that CMS may pay to a CJR-X participant after reconciliation as determined in accordance with § 512.650(g).
Reconciliation target price means the target price applied to an episode at reconciliation, as determined in accordance with § 512.645.
Region means one of the nine U.S. census divisions, as defined by the U.S. Census Bureau, with the U.S. territories included in Census Division 9.
Reorganization event means a merger, consolidation, spin-off or other restructuring that results in a new hospital entity under a given CCN.
Repayment amount means the amount that the CJR-X participant may owe to Medicare after reconciliation as determined in accordance with § 512.650(g).
Retrospective trend factor means the multiplier CMS uses in its reconciliation target price calculation to estimate realized changes in spending patterns during the performance year, calculated as set forth in § 512.645(f).
Rural hospital means an IPPS hospital that meets one of the following criteria:
(1) Is located in a rural area as defined under § 412.64 of this chapter.
(2) Is located in a rural census tract defined under § 412.103(a)(1) of this chapter.
Safety net hospital means a hospital in the top 25th percentile in their region for percentage of Medicare LEJR episodes provided to dually eligible beneficiaries during the applicable baseline period.
Sharing arrangement means a financial arrangement between a CJR-X participant and a CJR-X collaborator for the sole purpose of making gainsharing payments or alignment payments under CJR-X.
SNF stands for skilled nursing facility as defined in section 1819(a) of the Act.
Sole community hospital (SCH) means a hospital that meets the classification criteria specified in § 412.92 of this chapter.
Swing-bed hospital means a hospital that meets the definition specified in § 413.114 of this chapter.
TAA stands for total ankle arthroplasty.
TGP or therapy group practice means an entity that is enrolled in Medicare as a therapy group in private practice, includes at least one owner or employee who is a therapist in private practice, does not include an owner or employee who is a physician or nonphysician practitioner, and has a valid and active TIN.
THA means total hip arthroplasty.
Therapist means one of the following individuals as defined at § 484.4 of this chapter:
(1) Physical therapist.
(2) Occupational therapist.
(3) Speech-language pathologist.
Therapist in private practice means a therapist that—
(1) Complies with the special provisions for physical therapists in private practice in § 410.60(c) of this chapter;
(2) Complies with the special provisions for occupational therapists in private practice in § 410.59(c) of this chapter; or
(3) Complies with the special provisions for speech-language pathologists in private practice in § 410.62(c) of this chapter.
TIN stands for taxpayer identification number.
TKA stands for total knee arthroplasty.