§ 512.625 Scope of episode.
(a) Lower extremity joint replacement (LEJR) procedures. The MS-DRGs and HCPCS codes included in episodes are as follows:
(1) IPPS discharge under MS-DRG 469, 470, 521, or 522.
(2) OPPS claim for HCPCS codes 27130 or 27447.
(b) Included services. All Medicare Part A and B items and services are included in the episode, except as specified in paragraph (c) of this section. These items and 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 biologic, except for those excluded under paragraph (c) of this section.
(13) Hospice services.
(14) Part B professional claims dated in the 3 days prior to an anchor hospitalization if a claim for the surgical procedure for the same episode type is not detected as part of the hospitalization because the procedure was performed by the CJR-X participant on an outpatient basis, but the patient was subsequently admitted as an inpatient.
(c) Excluded services. The following items, services, and payments are excluded from the episode:
(1) Select items and services considered unrelated to the anchor hospitalization or the anchor procedure for episodes in the baseline period and performance year, including, but not limited to, the following:
(i) Inpatient hospital admissions for MS-DRGs that group to the following categories of diagnoses:
(A) Oncology.
(B) Trauma unrelated to the CJR-X episode.
(C) Organ transplant.
(D) Ventricular shunt.
(ii) Inpatient hospital admissions that fall into the following Major Diagnostic Categories (MDCs):
(A) MDC 02 (Diseases and Disorders of the Eye).
(B) MDC 14 (Pregnancy, Childbirth, and Puerperium).
(C) MDC 15 (Newborns).
(D) MDC 25 (Human Immunodeficiency Virus).
(2) New technology add-on payments, as defined in part 412, subpart F of this chapter for episodes in the baseline period and performance year.
(3) Transitional pass-through payments for medical devices as defined in § 419.66 of this chapter for episodes initiated in the baseline period and performance year.
(4) Hemophilia clotting factors provided in accordance with § 412.115 of this chapter for episodes in the baseline period and performance year.
(5) Part B payments for low-volume drugs, high-cost drugs and biologics, and blood clotting factors for hemophilia for episodes in the baseline period and performance year, billed on outpatient, carrier, and DME claims, defined as—
(i) Drug/biologic HCPCS codes that are billed in fewer than 31 episodes in total across all episodes in CJR-X during the baseline period;
(ii) Drug/biologic HCPCS codes that are billed in at least 31 episodes in the baseline period and have a mean allowed cost of greater than $25,000 per episode in the baseline period; and
(iii) HCPCS codes corresponding to clotting factors for hemophilia patients, identified in the quarterly average sales price file for certain Medicare Part B drugs and biologics as HCPCS codes with clotting factor equal to 1, HCPCS codes for new hemophilia clotting factors not included in the baseline period, and other HCPCS codes identified as hemophilia.
(6) Part B payments for low-volume drugs, high-cost drugs and biologics, and blood clotting factors for hemophilia for episodes initiated in the performance year, billed on outpatient, carrier, and DME claims, defined as—
(i) Drug/biologic HCPCS codes that were not captured in the baseline period and appear in 10 or fewer episodes in the relevant performance year;
(ii) Drug/biologic HCPCS codes that were not included in the baseline period, appear in more than 10 episodes in the relevant performance year, and have a mean cost of greater than $25,000 per episode in the relevant performance year; and
(iii) Drug/biologic HCPCS codes that were not included in the baseline period, appear in more than 10 episodes in the relevant performance year, have a mean cost of $25,000 or less per episode in the relevant performance year, and correspond to a drug/biologic that appears in the baseline period but was assigned a new HCPCS code between the baseline period and the relevant performance year.
(iv) HCPCS codes for new hemophilia clotting factors not included in the baseline period.
(d) CJR-X exclusions list. The list of excluded MS-DRGs, MDCs, and HCPCS codes is posted on the CMS website.
(e) Updating the CJR-X exclusions list. The list of excluded services is updated through rulemaking to reflect any of the following:
(1) Changes to the MS-DRGs under the IPPS.
(2) Coding changes.
(3) Other issues brought to CMS' attention.