§ 512.635 Quality measures, composite quality score, and display of quality measures.
(a) Quality measures. CMS calculates the quality measures used to evaluate the CJR-X participant's performance using Medicare claims data or patient-reported outcomes data reported under existing CMS quality reporting programs, including but not limited to the Hospital Inpatient Quality Reporting Program and the Hospital Outpatient Quality Reporting Program. The following quality measures are used for public reporting and for determining the CJR-X participant's CQS as described in paragraph (b) of this section:
(1) For all inpatient episodes: Hospital-level Risk-Standardized Complication Rate following elective primary Total Hip Arthroplasty and/or Total Knee Arthroplasty (CMIT ID #350).
(2) For all outpatient episodes: Hospital Visits within 7 days of Hospital Outpatient Department Surgery (CMIT ID #344, OP-36).
(3) For all inpatient episodes: Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS) (CMIT ID #338).
(4) For all outpatient episodes: Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Survey (OAS CAHPS) (CMIT #162, OP-46).
(5) For all inpatient episodes: Hospital-Level Total Hip and/or Total Knee Arthroplasty Patient-Reported Outcome-Based Performance Measure (PRO-PM) (CMIT ID #1618).
(b) Calculation of the composite quality score (CQS). CMS calculates an overall composite quality score during reconciliation, capped at 20 points, for each CJR-X participant for the relevant performance year. The overall composite quality score equals the sum of the inpatient measure composite quality score, as described in paragraph (b)(1) of this section, and the outpatient measure composite quality score, as described in paragraph (b)(2) of this section.
(1) CMS calculates the inpatient measure composite quality score by summing the CJR-X participant's quality performance points for all of the following:
(i) The measure identified in paragraph (a)(1) of this section. This measure is weighted at 50 percent of the inpatient composite quality score.
(ii) The measure identified in paragraph (a)(3) of this section. This measure is weighted at 40 percent of the inpatient composite quality score.
(iii) The measure identified in paragraph (a)(5) of this section. This measure is weighted at 10 percent of the inpatient composite quality score.
(2) CMS calculates the outpatient measure composite quality score by summing the CJR-X participant's quality performance points for all of the following:
(i) The measure identified in paragraphs (a)(2) of this section. This measure is weighted at 50 percent of the outpatient composite quality score.
(ii) The measure identified in paragraphs (a)(4) of this section. This measure is weighted at 40 percent of the outpatient composite quality score.
(iii) The measure identified in paragraph (a)(5) of this section. This measure is weighted at 10 percent of the inpatient composite quality score.
(c) Quality performance points. CMS calculates quality performance points for each quality measure based on the CJR-X participant's performance relative to the distribution of performance of all hospitals that are eligible for payment under IPPS and meet the minimum patient case or survey count for that measure.
(1) For the measures described in paragraphs (a)(1) and (a)(2) of this section, CMS assigns the CJR-X participant measure value to a performance percentile and then quality performance points are assigned based on the following performance percentile scale:
(i) 10.00 for ≥90th.
(ii) 9.25 for ≥80th and <90th.
(iii) 8.50 for ≥70th and <80th.
(iv) 7.75 for ≥60th and <70th.
(v) 7.00 for ≥50th and <60th.
(vi) 6.25 for ≥40th and <50th.
(vii) 5.50 for ≥30th and <40th.
(viii) 0.00 for <30th.
(2) For the measure described in paragraphs (a)(3) and (a)(4) of this section, CMS assigns the CJR-X participant measure value to a performance percentile and then quality performance points are assigned based on the following performance percentile scale:
(i) 8.00 for ≥90th.
(ii) 7.40 for ≥80th and <90th.
(iii) 6.80 for ≥70th and <80th.
(iv) 6.20 for ≥60th and <70th.
(v) 5.60 for ≥50th and <60th.
(vi) 5.00 for ≥40th and <50th.
(vii) 5.40 for ≥30th and <40th.
(viii) 0.00 for <30th.
(3) For the measure described in paragraph (a)(5) of this section, CMS assigns the CJR-X participant's measure value to a performance percentile and then CMS assigns quality performance points based on the following performance percentile scale:
(i) 2.00 for ≥90th.
(ii) 1.85 for ≥80th and <90th.
(iii) 1.70 for ≥70th and <80th.
(iv) 1.55 for ≥60th and <70th.
(v) 1.40 for ≥50th and <60th.
(vi) 1.25 for ≥40th and <50th.
(vii) 1.10 for ≥30th and <40th.
(viii) 0.00 for <30th.
(d) Exception for hospitals without a measure value.
(1) If the CJR-X participant is without a measure value that would allow CMS to assign quality performance points for that quality measure, CMS assigns the 50th percentile quality performance points to the CJR-X participant for the individual measure.
(2) A CJR-X participant will not have a measure value for—
(i) The measure described in paragraph (a)(1) of this section, if the CJR-X participant does not meet the minimum 25 patient case count.
(ii) The measure described in paragraph (a)(2) of this section, if the CJR-X participant does not meet the minimum 25 patient case count.
(iii) The measure described in paragraph (a)(3) of this section, if the CJR-X participant does not meet the minimum 100 completed surveys.
(iv) The measure described in paragraph (a)(4) of this section, if the CJR-X participant does not meet the minimum 100 completed surveys.
(v) The measure described in paragraph (a)(5) of this section, if the CJR-X participant does not meet the minimum 25 patient case count.
(e) Display of quality measures.
(1) CMS displays quality measure results on the publicly available CMS website that is specific to CJR-X, in a form and manner consistent with other publicly reported measures.
(2) CMS shares quality measures with the CJR-X participant prior to display on the CMS website. Quality measure performance in performance year 1 will be reported in Calendar Year 2029. Subsequent years will be reported in the year following the performance period.